MDedge Psychiatry

Nurse practitioners and physician assistants, rather than physicians, are the clinicians who have boosted capacity for buprenorphine prescribing in rural America, according to a study in a rural health–focused issue of the journal Health Affairs.

In the face of an ongoing crisis of opioid use disorder, and associated overdoses and deaths that have spared no sector of the U.S. population, the federal government expanded its waiver program for buprenorphine prescribing in 2017. The waiver expansion allows nurse practitioners (NPs) and physician assistants (PAs) – along with clinical nurse specialists, certified registered nurse anesthetists, and certified nurse-midwives – to use the drug for medication-assisted treatment (MAT) for opioid use disorder after completing 24 hours of mandated training; physicians are required to complete 8 hours of training to receive their waiver.

From 2016 to 2019, capacity for MAT in rural areas increased, with the number of clinicians with buprenorphine waivers more than doubling. Of the newly waivered prescribers accounting for this 111% increase, more than half were NPs and PAs.

In many areas, NPs and PAs led the way forward, wrote the study’s lead author Michael L. Barnett, MD, and coauthors, noting in the abstract accompanying the paper that “NPs and PAs accounted for more than half of this increase and were the first waivered clinicians in 285 rural counties with 5.7 million residents.” Overall, the proportion of people living in a county without a waivered clinician has decreased by 36% since NPs and PAs were permitted to obtain waivers.
 

SAMHSA data identifies trends

In an in-depth interview, Dr. Barnett, an internal medicine physician and health services researcher at the Harvard School of Public Health, Boston, said the issue today is “not so much continuing to dissect the risks and benefits of opioids as a treatment for pain, but more trying to address the current overdose crisis, and the fact that our patient treatment infrastructure is woefully inadequate for the magnitude of the problem that we face.”

Dr. Barnett’s chief intention for this study, he said, was to generate information that will drive policy to implement effective opioid treatment. He’d always been interested in models of care delivery that move beyond seeing just the physician-patient dyad.

“There are a whole range of nonphysician providers that are probably better at providing many different types of care – things that physicians aren’t necessarily that well trained to do,” he said.

Expansion of buprenorphine waivers to NPs and PAs, said Dr. Barnett, presented “a very interesting opportunity to see: How does a nonphysician workforce respond to a new practice opportunity, to really be engaged in areas that many physicians really were neglecting?”

The researchers used information drawn from what Dr. Barnett characterized as a “gold-standard” dataset maintained by the federal Substance Abuse and Mental Health Services Administration. They found that, by March 2019, 52% of U.S. rural residents lived in counties with at least one NP or PA holding a buprenorphine waiver, though there was wide geographic variation: Every county in Maine and New Hampshire had waivered NPs or PAs, but in Tennessee, just 3 of 95 counties had an NP or PA with a waiver.
 

Scope-of-practice regulations matter

The scope of practice permitted NPs and PAs varies by state, and Dr. Barnett and coauthors also looked to see whether broader scope of practice meant that more advanced practice clinicians were getting buprenorphine waivers. This did appear to be the case: In an analysis that dichotomized scope of practice into “broad” and “restricted,” states with broader practice scope saw twice as many waivered NPs per 100,000 rural residents as those with restrictive practice scope. This association was not seen for PAs, but Dr. Barnett pointed out that PAs are less likely overall to work in primary care.

This, he added, is where scope of practice starts to matter. “A lot of states are still bickering about scope of practice. We show in our paper the clear relationship between scope of practice and the degree to which providers are able to take up these waivers. We can’t prove causality, but I think it’s not a big stretch to think that these policies are playing a big role. I hope we’re working to try to advance that conversation.”

Helping address the unmet need for evidence-based treatment of opioid use disorder, he said, “is one of the more important examples, because doctors have been leaving rural areas in droves. We are lucky that there is a workforce of NPs that still seem to recognize the market opportunity; rural areas still need providers, and they have been willing to fill the gap.”

Waivered NPs or PAs can apply for an expanded waiver, permitting expansion of the buprenorphine panel from 30 to 100 patients after 1 year of holding their initial waiver. Physicians may apply for a waiver to treat up to 275 patients.
 

Effect on quality of care

The evidence doesn’t support big worries about quality of care, he said. “We don’t have any data on this in the clinical context of addiction, but all of the data that are out there in terms of evaluating the quality of care and level of care being offered by NPs and PAs versus primary care doctors – the types of things that we think of as within the scope of NP and PA practice typically – have shown that they are the same.” Dr. Barnett acknowledged that “there are a little bit of mixed results here and there in one direction or another, but largely, the care being delivered is much more the same than different.”

In addressing the opioid crisis as in the rest of medicine, it’s a mistake not to include this sector of the health care workforce when policies are being crafted, said Dr. Barnett. “People who are making policy and aren’t familiar with the workforce in rural areas could miss the boat. ... Everyone is often 10-20 years out of date in terms of how they think about the centrality of, specifically, the NP workforce, especially in rural areas. NPs aren’t just an asterisk to the workforce – they are an essential part of delivering medicine, just as much as physicians are.”

Dr. Barnett said that, in his estimation, “a lot of protectionist myths get physicians worked up around increased scope of practice for NPs.” However, “The truth is that there’s enough health care spending to go around for everybody and there’s plenty of work to go around.”

Dr. Barnett acknowledged that the current study captured only prescribing capacity, and not actual prescription volume. But, based on some preliminary data, “my sense is that NPs and PAs who acquire waivers are more likely to be prescribing to a larger number of patients proportionately than MDs.” He wasn’t surprised to see this, since the many more hours of training required for NPs and PAs to acquire a waiver means they’re likely to be committed to using the waiver in practice.

Stepping back to look at the bigger picture, Dr. Barnett remarked that, “taking a look at the waiver requirement, a part of me feels that it’s a bit of an anachronistic regulation, anyway – it’s really hard to justify clinically or ethically versus other things that we do.” The waiver program he said, is “a regulation barrier whose time should be limited. ... I’m hoping that the waiver disappears soon.”

Prescribing issues will linger beyond any future abolition of the waiver program, since many clinicians will still not be comfortable prescribing medication for MAT of opioid use disorder, said Dr. Barnett. “It’ll be a lot of the same stigma and structural barriers that were in place prior to the waiver.”

Dr. Barnett reported that he has been retained as an expert witness for plaintiffs in lawsuits against opioid manufacturers. The study was partly funded by the National Institutes of Health.

[email protected]

SOURCE: Barnett ML et al. Health Aff. 2019 Jan;38(12):2048-56.

Nurse practitioners and physician assistants, rather than physicians, are the clinicians who have boosted capacity for buprenorphine prescribing in rural America, according to a study in a rural health–focused issue of the journal Health Affairs.

In the face of an ongoing crisis of opioid use disorder, and associated overdoses and deaths that have spared no sector of the U.S. population, the federal government expanded its waiver program for buprenorphine prescribing in 2017. The waiver expansion allows nurse practitioners (NPs) and physician assistants (PAs) – along with clinical nurse specialists, certified registered nurse anesthetists, and certified nurse-midwives – to use the drug for medication-assisted treatment (MAT) for opioid use disorder after completing 24 hours of mandated training; physicians are required to complete 8 hours of training to receive their waiver.

From 2016 to 2019, capacity for MAT in rural areas increased, with the number of clinicians with buprenorphine waivers more than doubling. Of the newly waivered prescribers accounting for this 111% increase, more than half were NPs and PAs.

In many areas, NPs and PAs led the way forward, wrote the study’s lead author Michael L. Barnett, MD, and coauthors, noting in the abstract accompanying the paper that “NPs and PAs accounted for more than half of this increase and were the first waivered clinicians in 285 rural counties with 5.7 million residents.” Overall, the proportion of people living in a county without a waivered clinician has decreased by 36% since NPs and PAs were permitted to obtain waivers.
 

SAMHSA data identifies trends

In an in-depth interview, Dr. Barnett, an internal medicine physician and health services researcher at the Harvard School of Public Health, Boston, said the issue today is “not so much continuing to dissect the risks and benefits of opioids as a treatment for pain, but more trying to address the current overdose crisis, and the fact that our patient treatment infrastructure is woefully inadequate for the magnitude of the problem that we face.”

Dr. Barnett’s chief intention for this study, he said, was to generate information that will drive policy to implement effective opioid treatment. He’d always been interested in models of care delivery that move beyond seeing just the physician-patient dyad.

“There are a whole range of nonphysician providers that are probably better at providing many different types of care – things that physicians aren’t necessarily that well trained to do,” he said.

Expansion of buprenorphine waivers to NPs and PAs, said Dr. Barnett, presented “a very interesting opportunity to see: How does a nonphysician workforce respond to a new practice opportunity, to really be engaged in areas that many physicians really were neglecting?”

The researchers used information drawn from what Dr. Barnett characterized as a “gold-standard” dataset maintained by the federal Substance Abuse and Mental Health Services Administration. They found that, by March 2019, 52% of U.S. rural residents lived in counties with at least one NP or PA holding a buprenorphine waiver, though there was wide geographic variation: Every county in Maine and New Hampshire had waivered NPs or PAs, but in Tennessee, just 3 of 95 counties had an NP or PA with a waiver.
 

Scope-of-practice regulations matter

The scope of practice permitted NPs and PAs varies by state, and Dr. Barnett and coauthors also looked to see whether broader scope of practice meant that more advanced practice clinicians were getting buprenorphine waivers. This did appear to be the case: In an analysis that dichotomized scope of practice into “broad” and “restricted,” states with broader practice scope saw twice as many waivered NPs per 100,000 rural residents as those with restrictive practice scope. This association was not seen for PAs, but Dr. Barnett pointed out that PAs are less likely overall to work in primary care.

This, he added, is where scope of practice starts to matter. “A lot of states are still bickering about scope of practice. We show in our paper the clear relationship between scope of practice and the degree to which providers are able to take up these waivers. We can’t prove causality, but I think it’s not a big stretch to think that these policies are playing a big role. I hope we’re working to try to advance that conversation.”

Helping address the unmet need for evidence-based treatment of opioid use disorder, he said, “is one of the more important examples, because doctors have been leaving rural areas in droves. We are lucky that there is a workforce of NPs that still seem to recognize the market opportunity; rural areas still need providers, and they have been willing to fill the gap.”

Waivered NPs or PAs can apply for an expanded waiver, permitting expansion of the buprenorphine panel from 30 to 100 patients after 1 year of holding their initial waiver. Physicians may apply for a waiver to treat up to 275 patients.
 

Effect on quality of care

The evidence doesn’t support big worries about quality of care, he said. “We don’t have any data on this in the clinical context of addiction, but all of the data that are out there in terms of evaluating the quality of care and level of care being offered by NPs and PAs versus primary care doctors – the types of things that we think of as within the scope of NP and PA practice typically – have shown that they are the same.” Dr. Barnett acknowledged that “there are a little bit of mixed results here and there in one direction or another, but largely, the care being delivered is much more the same than different.”

In addressing the opioid crisis as in the rest of medicine, it’s a mistake not to include this sector of the health care workforce when policies are being crafted, said Dr. Barnett. “People who are making policy and aren’t familiar with the workforce in rural areas could miss the boat. ... Everyone is often 10-20 years out of date in terms of how they think about the centrality of, specifically, the NP workforce, especially in rural areas. NPs aren’t just an asterisk to the workforce – they are an essential part of delivering medicine, just as much as physicians are.”

Dr. Barnett said that, in his estimation, “a lot of protectionist myths get physicians worked up around increased scope of practice for NPs.” However, “The truth is that there’s enough health care spending to go around for everybody and there’s plenty of work to go around.”

Dr. Barnett acknowledged that the current study captured only prescribing capacity, and not actual prescription volume. But, based on some preliminary data, “my sense is that NPs and PAs who acquire waivers are more likely to be prescribing to a larger number of patients proportionately than MDs.” He wasn’t surprised to see this, since the many more hours of training required for NPs and PAs to acquire a waiver means they’re likely to be committed to using the waiver in practice.

Stepping back to look at the bigger picture, Dr. Barnett remarked that, “taking a look at the waiver requirement, a part of me feels that it’s a bit of an anachronistic regulation, anyway – it’s really hard to justify clinically or ethically versus other things that we do.” The waiver program he said, is “a regulation barrier whose time should be limited. ... I’m hoping that the waiver disappears soon.”

Prescribing issues will linger beyond any future abolition of the waiver program, since many clinicians will still not be comfortable prescribing medication for MAT of opioid use disorder, said Dr. Barnett. “It’ll be a lot of the same stigma and structural barriers that were in place prior to the waiver.”

Dr. Barnett reported that he has been retained as an expert witness for plaintiffs in lawsuits against opioid manufacturers. The study was partly funded by the National Institutes of Health.

[email protected]

SOURCE: Barnett ML et al. Health Aff. 2019 Jan;38(12):2048-56.

Nurse practitioners and physician assistants, rather than physicians, are the clinicians who have boosted capacity for buprenorphine prescribing in rural America, according to a study in a rural health–focused issue of the journal Health Affairs.

In the face of an ongoing crisis of opioid use disorder, and associated overdoses and deaths that have spared no sector of the U.S. population, the federal government expanded its waiver program for buprenorphine prescribing in 2017. The waiver expansion allows nurse practitioners (NPs) and physician assistants (PAs) – along with clinical nurse specialists, certified registered nurse anesthetists, and certified nurse-midwives – to use the drug for medication-assisted treatment (MAT) for opioid use disorder after completing 24 hours of mandated training; physicians are required to complete 8 hours of training to receive their waiver.

From 2016 to 2019, capacity for MAT in rural areas increased, with the number of clinicians with buprenorphine waivers more than doubling. Of the newly waivered prescribers accounting for this 111% increase, more than half were NPs and PAs.

In many areas, NPs and PAs led the way forward, wrote the study’s lead author Michael L. Barnett, MD, and coauthors, noting in the abstract accompanying the paper that “NPs and PAs accounted for more than half of this increase and were the first waivered clinicians in 285 rural counties with 5.7 million residents.” Overall, the proportion of people living in a county without a waivered clinician has decreased by 36% since NPs and PAs were permitted to obtain waivers.
 

SAMHSA data identifies trends

In an in-depth interview, Dr. Barnett, an internal medicine physician and health services researcher at the Harvard School of Public Health, Boston, said the issue today is “not so much continuing to dissect the risks and benefits of opioids as a treatment for pain, but more trying to address the current overdose crisis, and the fact that our patient treatment infrastructure is woefully inadequate for the magnitude of the problem that we face.”

Dr. Barnett’s chief intention for this study, he said, was to generate information that will drive policy to implement effective opioid treatment. He’d always been interested in models of care delivery that move beyond seeing just the physician-patient dyad.

“There are a whole range of nonphysician providers that are probably better at providing many different types of care – things that physicians aren’t necessarily that well trained to do,” he said.

Expansion of buprenorphine waivers to NPs and PAs, said Dr. Barnett, presented “a very interesting opportunity to see: How does a nonphysician workforce respond to a new practice opportunity, to really be engaged in areas that many physicians really were neglecting?”

The researchers used information drawn from what Dr. Barnett characterized as a “gold-standard” dataset maintained by the federal Substance Abuse and Mental Health Services Administration. They found that, by March 2019, 52% of U.S. rural residents lived in counties with at least one NP or PA holding a buprenorphine waiver, though there was wide geographic variation: Every county in Maine and New Hampshire had waivered NPs or PAs, but in Tennessee, just 3 of 95 counties had an NP or PA with a waiver.
 

Scope-of-practice regulations matter

The scope of practice permitted NPs and PAs varies by state, and Dr. Barnett and coauthors also looked to see whether broader scope of practice meant that more advanced practice clinicians were getting buprenorphine waivers. This did appear to be the case: In an analysis that dichotomized scope of practice into “broad” and “restricted,” states with broader practice scope saw twice as many waivered NPs per 100,000 rural residents as those with restrictive practice scope. This association was not seen for PAs, but Dr. Barnett pointed out that PAs are less likely overall to work in primary care.

This, he added, is where scope of practice starts to matter. “A lot of states are still bickering about scope of practice. We show in our paper the clear relationship between scope of practice and the degree to which providers are able to take up these waivers. We can’t prove causality, but I think it’s not a big stretch to think that these policies are playing a big role. I hope we’re working to try to advance that conversation.”

Helping address the unmet need for evidence-based treatment of opioid use disorder, he said, “is one of the more important examples, because doctors have been leaving rural areas in droves. We are lucky that there is a workforce of NPs that still seem to recognize the market opportunity; rural areas still need providers, and they have been willing to fill the gap.”

Waivered NPs or PAs can apply for an expanded waiver, permitting expansion of the buprenorphine panel from 30 to 100 patients after 1 year of holding their initial waiver. Physicians may apply for a waiver to treat up to 275 patients.
 

Effect on quality of care

The evidence doesn’t support big worries about quality of care, he said. “We don’t have any data on this in the clinical context of addiction, but all of the data that are out there in terms of evaluating the quality of care and level of care being offered by NPs and PAs versus primary care doctors – the types of things that we think of as within the scope of NP and PA practice typically – have shown that they are the same.” Dr. Barnett acknowledged that “there are a little bit of mixed results here and there in one direction or another, but largely, the care being delivered is much more the same than different.”

In addressing the opioid crisis as in the rest of medicine, it’s a mistake not to include this sector of the health care workforce when policies are being crafted, said Dr. Barnett. “People who are making policy and aren’t familiar with the workforce in rural areas could miss the boat. ... Everyone is often 10-20 years out of date in terms of how they think about the centrality of, specifically, the NP workforce, especially in rural areas. NPs aren’t just an asterisk to the workforce – they are an essential part of delivering medicine, just as much as physicians are.”

Dr. Barnett said that, in his estimation, “a lot of protectionist myths get physicians worked up around increased scope of practice for NPs.” However, “The truth is that there’s enough health care spending to go around for everybody and there’s plenty of work to go around.”

Dr. Barnett acknowledged that the current study captured only prescribing capacity, and not actual prescription volume. But, based on some preliminary data, “my sense is that NPs and PAs who acquire waivers are more likely to be prescribing to a larger number of patients proportionately than MDs.” He wasn’t surprised to see this, since the many more hours of training required for NPs and PAs to acquire a waiver means they’re likely to be committed to using the waiver in practice.

Stepping back to look at the bigger picture, Dr. Barnett remarked that, “taking a look at the waiver requirement, a part of me feels that it’s a bit of an anachronistic regulation, anyway – it’s really hard to justify clinically or ethically versus other things that we do.” The waiver program he said, is “a regulation barrier whose time should be limited. ... I’m hoping that the waiver disappears soon.”

Prescribing issues will linger beyond any future abolition of the waiver program, since many clinicians will still not be comfortable prescribing medication for MAT of opioid use disorder, said Dr. Barnett. “It’ll be a lot of the same stigma and structural barriers that were in place prior to the waiver.”

Dr. Barnett reported that he has been retained as an expert witness for plaintiffs in lawsuits against opioid manufacturers. The study was partly funded by the National Institutes of Health.

[email protected]

SOURCE: Barnett ML et al. Health Aff. 2019 Jan;38(12):2048-56.

Forty-one percent of U.S. psychiatrists have been sued for malpractice at least once, findings from the newly released Medscape Psychiatrist Malpractice Report 2019 show.

The top reason for the legal action was wrongful death (31%), followed by poor outcome/disease progression (23%), failure to treat/delayed treatment (11%), errors in medication administration (10%), and complications from treatment/surgery (8%).

Only 7% of psychiatrists said failure to treat/delayed treatment was the reason for the lawsuit, whereas this was the top reason for physicians overall (33%) in the report.

Medscape surveyed 4,360 physician members in more than 25 specialties about whether they have been sued for malpractice, reasons for a lawsuit, what happened, and how the experience affected the way they practice medicine and interact with patients.

Among psychiatrists named in a lawsuit, 44% said they were very surprised to be the subject of litigation. A similar percentage reported they were somewhat surprised (41%), while 15% were not at all surprised.

The vast majority of psychiatrists (87%) believed the lawsuit was not warranted, while 11% were unsure. Only a small percentage (2%) believed that legal action was justified, the lowest percentage of all physicians (6%).

Among psychiatrists who were sued, 42% were able to identify the incident that sparked the lawsuit. A slightly higher percentage (47%) said there was no specific incident that spurred legal action; 11% couldn’t recall.

Psychological factors

“There’s a whole host of what you could call psychological factors that can contribute to the filing of a claim,” David S. Szabo, a malpractice defense attorney with Locke Lord LLP, Boston, said in an interview.

“These can occur when a patient perceives a breakdown in the doctor-patient relationship or is pretty certain that there’s been a mistake and they feel like they’ve been shut out of productive conversation with their health care provider or providers,” said Mr. Szabo.

Legal action eats up time. A total of 43% of psychiatrists reported spending more than 40 hours on their defense, which involved gathering records, meeting with attorneys, and preparing for depositions.

Forty-six percent reported that the entire process took 1-2 years to resolve, but nearly a quarter (23%) said the process dragged on for 3-5 years.

One-third of psychiatrists who were named in a malpractice lawsuit said the case was settled out of court. Of the cases that went to trial, 12% of psychiatrists reported that the verdict was in their favor; 3% reported that the outcome of the case was in the plaintiff’s favor.

Asked why they think most malpractice lawsuits occurred, 61% of psychiatrists said that patients don’t understand medical risks and blame the doctor for bad outcomes even if the doctor does everything right.

A similar percentage of psychiatrists recognized that if a true medical error has occurred, patients wanted to seek restitution and/or assign blame. Only 29% of psychiatrists felt that constant advertising by lawyers to get new clients was the reason for most malpractice cases.

The overwhelming majority of psychiatrists (93%) who responded to the survey carry malpractice insurance, about the same as physicians overall (94%).

Among those with malpractice coverage who either settled or went to trial, about half were either encouraged by their insurer to settle the case or were required by their insurer to do so.

“Generally, if a physician senses that he or she is heading toward a difference of opinion with the insurer about settlement, they probably ought to invest a little time in having personal counsel look at the case,” Mr. Szabo said.

Practice changing?

Facing a lawsuit can be devastating for any physician, but nearly half (48%) of psychiatrists surveyed said they made no changes after the case was resolved.

Just over a quarter (27%) of psychiatrists said the legal action prompted a change in their approach to patients. In addition, 8% said they left their practice setting, and 3% said they bought more malpractice insurance.

Among psychiatrist cases that resulted in a settlement or a verdict in the plaintiff’s favor, nearly half (48%) of monetary awards maxed out at $100,000, while 31% maxed out at $500,000, and 8% at $1 million.

More than half of psychiatrists (55%) named in a lawsuit believed the outcome of the case was fair; 45% felt it was unfair.

Psychiatrists reported that, in retrospect, they would have done several things differently. These included maintaining better documentation of their patient’s chart (20%) and not taking on the patient in the first place (15%), followed by spending more time with the patient and his/her family (11%), getting a second opinion from a colleague (9%), and reviewing the history/chart more carefully (7%).

About three-quarters of psychiatrists felt that saying sorry or offering an apology to the patient would not have prevented the lawsuit. This is a lower percentage than was indicated by all physicians (82%) who have been sued.

Psychiatrists believe the best ways to discourage lawsuits is through better patient communication and rapport (59%) and having a medical panel screen cases for merit (50%).

About half of psychiatrists (51%) and more than half (56%) of all physicians believe that medical organizations or state societies are not doing enough to discourage malpractice cases.

This article first appeared on Medscape.com.

Forty-one percent of U.S. psychiatrists have been sued for malpractice at least once, findings from the newly released Medscape Psychiatrist Malpractice Report 2019 show.

The top reason for the legal action was wrongful death (31%), followed by poor outcome/disease progression (23%), failure to treat/delayed treatment (11%), errors in medication administration (10%), and complications from treatment/surgery (8%).

Only 7% of psychiatrists said failure to treat/delayed treatment was the reason for the lawsuit, whereas this was the top reason for physicians overall (33%) in the report.

Medscape surveyed 4,360 physician members in more than 25 specialties about whether they have been sued for malpractice, reasons for a lawsuit, what happened, and how the experience affected the way they practice medicine and interact with patients.

Among psychiatrists named in a lawsuit, 44% said they were very surprised to be the subject of litigation. A similar percentage reported they were somewhat surprised (41%), while 15% were not at all surprised.

The vast majority of psychiatrists (87%) believed the lawsuit was not warranted, while 11% were unsure. Only a small percentage (2%) believed that legal action was justified, the lowest percentage of all physicians (6%).

Among psychiatrists who were sued, 42% were able to identify the incident that sparked the lawsuit. A slightly higher percentage (47%) said there was no specific incident that spurred legal action; 11% couldn’t recall.

Psychological factors

“There’s a whole host of what you could call psychological factors that can contribute to the filing of a claim,” David S. Szabo, a malpractice defense attorney with Locke Lord LLP, Boston, said in an interview.

“These can occur when a patient perceives a breakdown in the doctor-patient relationship or is pretty certain that there’s been a mistake and they feel like they’ve been shut out of productive conversation with their health care provider or providers,” said Mr. Szabo.

Legal action eats up time. A total of 43% of psychiatrists reported spending more than 40 hours on their defense, which involved gathering records, meeting with attorneys, and preparing for depositions.

Forty-six percent reported that the entire process took 1-2 years to resolve, but nearly a quarter (23%) said the process dragged on for 3-5 years.

One-third of psychiatrists who were named in a malpractice lawsuit said the case was settled out of court. Of the cases that went to trial, 12% of psychiatrists reported that the verdict was in their favor; 3% reported that the outcome of the case was in the plaintiff’s favor.

Asked why they think most malpractice lawsuits occurred, 61% of psychiatrists said that patients don’t understand medical risks and blame the doctor for bad outcomes even if the doctor does everything right.

A similar percentage of psychiatrists recognized that if a true medical error has occurred, patients wanted to seek restitution and/or assign blame. Only 29% of psychiatrists felt that constant advertising by lawyers to get new clients was the reason for most malpractice cases.

The overwhelming majority of psychiatrists (93%) who responded to the survey carry malpractice insurance, about the same as physicians overall (94%).

Among those with malpractice coverage who either settled or went to trial, about half were either encouraged by their insurer to settle the case or were required by their insurer to do so.

“Generally, if a physician senses that he or she is heading toward a difference of opinion with the insurer about settlement, they probably ought to invest a little time in having personal counsel look at the case,” Mr. Szabo said.

Practice changing?

Facing a lawsuit can be devastating for any physician, but nearly half (48%) of psychiatrists surveyed said they made no changes after the case was resolved.

Just over a quarter (27%) of psychiatrists said the legal action prompted a change in their approach to patients. In addition, 8% said they left their practice setting, and 3% said they bought more malpractice insurance.

Among psychiatrist cases that resulted in a settlement or a verdict in the plaintiff’s favor, nearly half (48%) of monetary awards maxed out at $100,000, while 31% maxed out at $500,000, and 8% at $1 million.

More than half of psychiatrists (55%) named in a lawsuit believed the outcome of the case was fair; 45% felt it was unfair.

Psychiatrists reported that, in retrospect, they would have done several things differently. These included maintaining better documentation of their patient’s chart (20%) and not taking on the patient in the first place (15%), followed by spending more time with the patient and his/her family (11%), getting a second opinion from a colleague (9%), and reviewing the history/chart more carefully (7%).

About three-quarters of psychiatrists felt that saying sorry or offering an apology to the patient would not have prevented the lawsuit. This is a lower percentage than was indicated by all physicians (82%) who have been sued.

Psychiatrists believe the best ways to discourage lawsuits is through better patient communication and rapport (59%) and having a medical panel screen cases for merit (50%).

About half of psychiatrists (51%) and more than half (56%) of all physicians believe that medical organizations or state societies are not doing enough to discourage malpractice cases.

This article first appeared on Medscape.com.

Forty-one percent of U.S. psychiatrists have been sued for malpractice at least once, findings from the newly released Medscape Psychiatrist Malpractice Report 2019 show.

The top reason for the legal action was wrongful death (31%), followed by poor outcome/disease progression (23%), failure to treat/delayed treatment (11%), errors in medication administration (10%), and complications from treatment/surgery (8%).

Only 7% of psychiatrists said failure to treat/delayed treatment was the reason for the lawsuit, whereas this was the top reason for physicians overall (33%) in the report.

Medscape surveyed 4,360 physician members in more than 25 specialties about whether they have been sued for malpractice, reasons for a lawsuit, what happened, and how the experience affected the way they practice medicine and interact with patients.

Among psychiatrists named in a lawsuit, 44% said they were very surprised to be the subject of litigation. A similar percentage reported they were somewhat surprised (41%), while 15% were not at all surprised.

The vast majority of psychiatrists (87%) believed the lawsuit was not warranted, while 11% were unsure. Only a small percentage (2%) believed that legal action was justified, the lowest percentage of all physicians (6%).

Among psychiatrists who were sued, 42% were able to identify the incident that sparked the lawsuit. A slightly higher percentage (47%) said there was no specific incident that spurred legal action; 11% couldn’t recall.

Psychological factors

“There’s a whole host of what you could call psychological factors that can contribute to the filing of a claim,” David S. Szabo, a malpractice defense attorney with Locke Lord LLP, Boston, said in an interview.

“These can occur when a patient perceives a breakdown in the doctor-patient relationship or is pretty certain that there’s been a mistake and they feel like they’ve been shut out of productive conversation with their health care provider or providers,” said Mr. Szabo.

Legal action eats up time. A total of 43% of psychiatrists reported spending more than 40 hours on their defense, which involved gathering records, meeting with attorneys, and preparing for depositions.

Forty-six percent reported that the entire process took 1-2 years to resolve, but nearly a quarter (23%) said the process dragged on for 3-5 years.

One-third of psychiatrists who were named in a malpractice lawsuit said the case was settled out of court. Of the cases that went to trial, 12% of psychiatrists reported that the verdict was in their favor; 3% reported that the outcome of the case was in the plaintiff’s favor.

Asked why they think most malpractice lawsuits occurred, 61% of psychiatrists said that patients don’t understand medical risks and blame the doctor for bad outcomes even if the doctor does everything right.

A similar percentage of psychiatrists recognized that if a true medical error has occurred, patients wanted to seek restitution and/or assign blame. Only 29% of psychiatrists felt that constant advertising by lawyers to get new clients was the reason for most malpractice cases.

The overwhelming majority of psychiatrists (93%) who responded to the survey carry malpractice insurance, about the same as physicians overall (94%).

Among those with malpractice coverage who either settled or went to trial, about half were either encouraged by their insurer to settle the case or were required by their insurer to do so.

“Generally, if a physician senses that he or she is heading toward a difference of opinion with the insurer about settlement, they probably ought to invest a little time in having personal counsel look at the case,” Mr. Szabo said.

Practice changing?

Facing a lawsuit can be devastating for any physician, but nearly half (48%) of psychiatrists surveyed said they made no changes after the case was resolved.

Just over a quarter (27%) of psychiatrists said the legal action prompted a change in their approach to patients. In addition, 8% said they left their practice setting, and 3% said they bought more malpractice insurance.

Among psychiatrist cases that resulted in a settlement or a verdict in the plaintiff’s favor, nearly half (48%) of monetary awards maxed out at $100,000, while 31% maxed out at $500,000, and 8% at $1 million.

More than half of psychiatrists (55%) named in a lawsuit believed the outcome of the case was fair; 45% felt it was unfair.

Psychiatrists reported that, in retrospect, they would have done several things differently. These included maintaining better documentation of their patient’s chart (20%) and not taking on the patient in the first place (15%), followed by spending more time with the patient and his/her family (11%), getting a second opinion from a colleague (9%), and reviewing the history/chart more carefully (7%).

About three-quarters of psychiatrists felt that saying sorry or offering an apology to the patient would not have prevented the lawsuit. This is a lower percentage than was indicated by all physicians (82%) who have been sued.

Psychiatrists believe the best ways to discourage lawsuits is through better patient communication and rapport (59%) and having a medical panel screen cases for merit (50%).

About half of psychiatrists (51%) and more than half (56%) of all physicians believe that medical organizations or state societies are not doing enough to discourage malpractice cases.

This article first appeared on Medscape.com.

The Food and Drug Administration is strengthening a previous warning regarding the uncommon risk of serious bowel complications associated with the schizophrenia medication clozapine (Clozaril, FazaClo ODT, Versacloz).

Wikimedia Commons/FitzColinGerald/ Creative Commons License

According to the FDA press release, dated Jan. 28, clozapine affects bowel function in a majority of patients, and constipation is a common adverse event associated with clozapine use. This can uncommonly progress to serious bowel complications, including complete bowel blockage, and can result in hospitalization or even death if the constipation is not diagnosed and treated quickly.

Patients should contact their health care clinician if their bowel movements are less frequent, they have a bowel movement less than three times a week, they have hard or dry stool, or they have difficulty passing gas. Urgent care is needed if patients are experiencing nausea, vomiting, belly pain, or bloating, according to the FDA.

In addition, health care clinicians should evaluate bowel function before beginning clozapine treatment, avoid coprescribing with other anticholinergic medicines, advise and question patients about the risks of clozapine and their bowel movements, monitor patients for complications, and consider prophylactic laxative treatment in patients with a history of constipation or bowel obstruction, the FDA added.

[email protected]

The Food and Drug Administration is strengthening a previous warning regarding the uncommon risk of serious bowel complications associated with the schizophrenia medication clozapine (Clozaril, FazaClo ODT, Versacloz).

Wikimedia Commons/FitzColinGerald/ Creative Commons License

According to the FDA press release, dated Jan. 28, clozapine affects bowel function in a majority of patients, and constipation is a common adverse event associated with clozapine use. This can uncommonly progress to serious bowel complications, including complete bowel blockage, and can result in hospitalization or even death if the constipation is not diagnosed and treated quickly.

Patients should contact their health care clinician if their bowel movements are less frequent, they have a bowel movement less than three times a week, they have hard or dry stool, or they have difficulty passing gas. Urgent care is needed if patients are experiencing nausea, vomiting, belly pain, or bloating, according to the FDA.

In addition, health care clinicians should evaluate bowel function before beginning clozapine treatment, avoid coprescribing with other anticholinergic medicines, advise and question patients about the risks of clozapine and their bowel movements, monitor patients for complications, and consider prophylactic laxative treatment in patients with a history of constipation or bowel obstruction, the FDA added.

[email protected]

The Food and Drug Administration is strengthening a previous warning regarding the uncommon risk of serious bowel complications associated with the schizophrenia medication clozapine (Clozaril, FazaClo ODT, Versacloz).

Wikimedia Commons/FitzColinGerald/ Creative Commons License

According to the FDA press release, dated Jan. 28, clozapine affects bowel function in a majority of patients, and constipation is a common adverse event associated with clozapine use. This can uncommonly progress to serious bowel complications, including complete bowel blockage, and can result in hospitalization or even death if the constipation is not diagnosed and treated quickly.

Patients should contact their health care clinician if their bowel movements are less frequent, they have a bowel movement less than three times a week, they have hard or dry stool, or they have difficulty passing gas. Urgent care is needed if patients are experiencing nausea, vomiting, belly pain, or bloating, according to the FDA.

In addition, health care clinicians should evaluate bowel function before beginning clozapine treatment, avoid coprescribing with other anticholinergic medicines, advise and question patients about the risks of clozapine and their bowel movements, monitor patients for complications, and consider prophylactic laxative treatment in patients with a history of constipation or bowel obstruction, the FDA added.

[email protected]

A Washington Post article on depression after miscarriage is a reminder that, although couples can suffer deeply from such a loss, there still are ways to provide them with meaningful support (“After miscarriage, I was rocked by depression. Like many other women, I didn’t get follow-up care for this loss,” by Katie C. Reilly, Nov 30, 2019).

Carlo107/Getty Images

Psychiatrists who focus on reproductive psychiatry and collaborative care are trying to change the current therapeutic landscape and improve practitioner awareness and treatment. Ob.gyns. managing patients who have experienced reproductive loss, especially early-term loss, may not immediately refer couples to a therapist or psychiatrist, but we can change this. Practitioners who focus on reproductive health – both physical and mental – are trying to better understand such couples’ experiences, increase their access to care, develop preventative care strategies, and improve provider education.

At the outset, providers who treat patients who have experienced a perinatal loss must recognize that not all individuals will feel that a loss is tragic. Instead, patient reactions occur along a spectrum, and there is no “correct” way to process a loss. A couple’s reaction may depend on a variety of factors, including how late or early in pregnancy the loss occurs, whether the pregnancy is planned or unplanned, and what other psychosocial stressors, such as unstable housing, limited income, and few social supports, may exist. Not every patient experiencing grief, even profoundly, will shed tears; we need to be open to all potential reactions and be mindful when a person may need additional support.

According to the Washington Post article, even though 50% of miscarriages are due to chromosomal abnormalities, women still feel ultimately responsible for the loss. As a society we are bombarded with “experts” in the media telling us the best way, the right way, the healthiest way to live. This barrage of advice distorts our views of what it really means to be a good parent and subtly conveys the idea that mothers are solely responsible for any bad pregnancy outcomes. I remember being fearful of causing unintentional harm to my unborn baby during my own pregnancy. What if I accidentally ate something that would affect her development? Is exposure to second-hand smoke as I walk down the street harming her? How bad would it be if I just had one cup of coffee? My doubts caused quite a bit of distress for me, which is a mild form of the distress I see when counseling couples after their miscarriages.

The article’s author also expressed concern about the emotional sterility of the environment in which miscarriages usually occur: a hospital ED. EDs are designed to promote a level of detachment and to quell any stress for the clinicians so that they can calmly handle unexpected health crises. EDs are not primarily designed to provide patients with emotional support, nor should they be. However, we still can make some improvements to existing ED design to better address couples’ emotional needs. For example, some EDs have placed mental health clinicians on staff, others call patients post discharge to address concerns, and some EDs even provide patients access to mental health trauma teams. Such services are not found in all EDs, and even those that exist may just scratch the surface of what is needed, but they are a step in the right direction. Providing this level of auxiliary care directly from the ED increases patients’ ability to access mental health support in the place where miscarriages are most likely to be first diagnosed and managed.

The American College of Obstetricians and Gynecologists already is trying to fill in the missing pieces when it comes to identifying mood symptoms following miscarriage. One of the key recommendations from the May 2018 Committee Opinion on Redefining the Postpartum Visit is that every woman who has experienced a miscarriage, stillbirth, or neonatal death should receive follow-up care. Mental health is a suggested component of the postpartum care plan. Some outpatient ob.gyn. practices and inpatient units are using screening tools to identify postpartum depression. For example, the Edinburgh Postnatal Depression Scale can be utilized following a miscarriage to help providers identify symptoms of depression and anxiety.

However, advancements in screening practices are only the tip of the iceberg of helping patients following miscarriage. A major question is how do we provide treatment? The trend in psychiatry over the past decade has been toward collaborative care, models that embed psychiatrists and other mental health clinicians in ob.gyn. practices to help guide the diagnosis and treatment of mental health problems. Some psychiatrists practice a co-located model in which they see patients alongside their ob.gyn. colleagues, whereas other psychiatrists treat a larger number of patients by using chart reviews for medication management while relying on behavioral health care managers for counseling and monitoring. Using this model of mental health care, more patients have access to services that are provided in a location familiar to them.

Another step in the right direction is the October 2019 launch of The National Curriculum in Reproductive Psychiatry (NCRP), which provides free educational material for psychiatry faculty and residents to enhance education on topics related to reproductive psychiatry, including miscarriage, loss, and development of trauma disorders. NCRP aspires to develop educational materials for ob.gyn. residents.

In the past we may have missed the mark in recognizing and treating the trauma that prenatal loss can cause, but we are trying to improve our approaches. More and more couples are sharing their experiences and advocating for themselves and others, often creating change in medical practice, and doctors are starting to listen. As any clinician knows, changes to standards of care can take several years to disseminate into general practice, but this gap between knowledge and treatment is now in the forefront of our minds. I am hopeful that we will continue to make advances and provide better care to our patients who have endured the loss of a pregnancy.
 

Dr. Latorre is an assistant professor in the department of psychiatry at the University of Maryland School of Medicine. She has reported no relevant financial disclosures. Email her at [email protected].

A Washington Post article on depression after miscarriage is a reminder that, although couples can suffer deeply from such a loss, there still are ways to provide them with meaningful support (“After miscarriage, I was rocked by depression. Like many other women, I didn’t get follow-up care for this loss,” by Katie C. Reilly, Nov 30, 2019).

Carlo107/Getty Images

Psychiatrists who focus on reproductive psychiatry and collaborative care are trying to change the current therapeutic landscape and improve practitioner awareness and treatment. Ob.gyns. managing patients who have experienced reproductive loss, especially early-term loss, may not immediately refer couples to a therapist or psychiatrist, but we can change this. Practitioners who focus on reproductive health – both physical and mental – are trying to better understand such couples’ experiences, increase their access to care, develop preventative care strategies, and improve provider education.

At the outset, providers who treat patients who have experienced a perinatal loss must recognize that not all individuals will feel that a loss is tragic. Instead, patient reactions occur along a spectrum, and there is no “correct” way to process a loss. A couple’s reaction may depend on a variety of factors, including how late or early in pregnancy the loss occurs, whether the pregnancy is planned or unplanned, and what other psychosocial stressors, such as unstable housing, limited income, and few social supports, may exist. Not every patient experiencing grief, even profoundly, will shed tears; we need to be open to all potential reactions and be mindful when a person may need additional support.

According to the Washington Post article, even though 50% of miscarriages are due to chromosomal abnormalities, women still feel ultimately responsible for the loss. As a society we are bombarded with “experts” in the media telling us the best way, the right way, the healthiest way to live. This barrage of advice distorts our views of what it really means to be a good parent and subtly conveys the idea that mothers are solely responsible for any bad pregnancy outcomes. I remember being fearful of causing unintentional harm to my unborn baby during my own pregnancy. What if I accidentally ate something that would affect her development? Is exposure to second-hand smoke as I walk down the street harming her? How bad would it be if I just had one cup of coffee? My doubts caused quite a bit of distress for me, which is a mild form of the distress I see when counseling couples after their miscarriages.

The article’s author also expressed concern about the emotional sterility of the environment in which miscarriages usually occur: a hospital ED. EDs are designed to promote a level of detachment and to quell any stress for the clinicians so that they can calmly handle unexpected health crises. EDs are not primarily designed to provide patients with emotional support, nor should they be. However, we still can make some improvements to existing ED design to better address couples’ emotional needs. For example, some EDs have placed mental health clinicians on staff, others call patients post discharge to address concerns, and some EDs even provide patients access to mental health trauma teams. Such services are not found in all EDs, and even those that exist may just scratch the surface of what is needed, but they are a step in the right direction. Providing this level of auxiliary care directly from the ED increases patients’ ability to access mental health support in the place where miscarriages are most likely to be first diagnosed and managed.

The American College of Obstetricians and Gynecologists already is trying to fill in the missing pieces when it comes to identifying mood symptoms following miscarriage. One of the key recommendations from the May 2018 Committee Opinion on Redefining the Postpartum Visit is that every woman who has experienced a miscarriage, stillbirth, or neonatal death should receive follow-up care. Mental health is a suggested component of the postpartum care plan. Some outpatient ob.gyn. practices and inpatient units are using screening tools to identify postpartum depression. For example, the Edinburgh Postnatal Depression Scale can be utilized following a miscarriage to help providers identify symptoms of depression and anxiety.

However, advancements in screening practices are only the tip of the iceberg of helping patients following miscarriage. A major question is how do we provide treatment? The trend in psychiatry over the past decade has been toward collaborative care, models that embed psychiatrists and other mental health clinicians in ob.gyn. practices to help guide the diagnosis and treatment of mental health problems. Some psychiatrists practice a co-located model in which they see patients alongside their ob.gyn. colleagues, whereas other psychiatrists treat a larger number of patients by using chart reviews for medication management while relying on behavioral health care managers for counseling and monitoring. Using this model of mental health care, more patients have access to services that are provided in a location familiar to them.

Another step in the right direction is the October 2019 launch of The National Curriculum in Reproductive Psychiatry (NCRP), which provides free educational material for psychiatry faculty and residents to enhance education on topics related to reproductive psychiatry, including miscarriage, loss, and development of trauma disorders. NCRP aspires to develop educational materials for ob.gyn. residents.

In the past we may have missed the mark in recognizing and treating the trauma that prenatal loss can cause, but we are trying to improve our approaches. More and more couples are sharing their experiences and advocating for themselves and others, often creating change in medical practice, and doctors are starting to listen. As any clinician knows, changes to standards of care can take several years to disseminate into general practice, but this gap between knowledge and treatment is now in the forefront of our minds. I am hopeful that we will continue to make advances and provide better care to our patients who have endured the loss of a pregnancy.
 

Dr. Latorre is an assistant professor in the department of psychiatry at the University of Maryland School of Medicine. She has reported no relevant financial disclosures. Email her at [email protected].

A Washington Post article on depression after miscarriage is a reminder that, although couples can suffer deeply from such a loss, there still are ways to provide them with meaningful support (“After miscarriage, I was rocked by depression. Like many other women, I didn’t get follow-up care for this loss,” by Katie C. Reilly, Nov 30, 2019).

Carlo107/Getty Images

Psychiatrists who focus on reproductive psychiatry and collaborative care are trying to change the current therapeutic landscape and improve practitioner awareness and treatment. Ob.gyns. managing patients who have experienced reproductive loss, especially early-term loss, may not immediately refer couples to a therapist or psychiatrist, but we can change this. Practitioners who focus on reproductive health – both physical and mental – are trying to better understand such couples’ experiences, increase their access to care, develop preventative care strategies, and improve provider education.

At the outset, providers who treat patients who have experienced a perinatal loss must recognize that not all individuals will feel that a loss is tragic. Instead, patient reactions occur along a spectrum, and there is no “correct” way to process a loss. A couple’s reaction may depend on a variety of factors, including how late or early in pregnancy the loss occurs, whether the pregnancy is planned or unplanned, and what other psychosocial stressors, such as unstable housing, limited income, and few social supports, may exist. Not every patient experiencing grief, even profoundly, will shed tears; we need to be open to all potential reactions and be mindful when a person may need additional support.

According to the Washington Post article, even though 50% of miscarriages are due to chromosomal abnormalities, women still feel ultimately responsible for the loss. As a society we are bombarded with “experts” in the media telling us the best way, the right way, the healthiest way to live. This barrage of advice distorts our views of what it really means to be a good parent and subtly conveys the idea that mothers are solely responsible for any bad pregnancy outcomes. I remember being fearful of causing unintentional harm to my unborn baby during my own pregnancy. What if I accidentally ate something that would affect her development? Is exposure to second-hand smoke as I walk down the street harming her? How bad would it be if I just had one cup of coffee? My doubts caused quite a bit of distress for me, which is a mild form of the distress I see when counseling couples after their miscarriages.

The article’s author also expressed concern about the emotional sterility of the environment in which miscarriages usually occur: a hospital ED. EDs are designed to promote a level of detachment and to quell any stress for the clinicians so that they can calmly handle unexpected health crises. EDs are not primarily designed to provide patients with emotional support, nor should they be. However, we still can make some improvements to existing ED design to better address couples’ emotional needs. For example, some EDs have placed mental health clinicians on staff, others call patients post discharge to address concerns, and some EDs even provide patients access to mental health trauma teams. Such services are not found in all EDs, and even those that exist may just scratch the surface of what is needed, but they are a step in the right direction. Providing this level of auxiliary care directly from the ED increases patients’ ability to access mental health support in the place where miscarriages are most likely to be first diagnosed and managed.

The American College of Obstetricians and Gynecologists already is trying to fill in the missing pieces when it comes to identifying mood symptoms following miscarriage. One of the key recommendations from the May 2018 Committee Opinion on Redefining the Postpartum Visit is that every woman who has experienced a miscarriage, stillbirth, or neonatal death should receive follow-up care. Mental health is a suggested component of the postpartum care plan. Some outpatient ob.gyn. practices and inpatient units are using screening tools to identify postpartum depression. For example, the Edinburgh Postnatal Depression Scale can be utilized following a miscarriage to help providers identify symptoms of depression and anxiety.

However, advancements in screening practices are only the tip of the iceberg of helping patients following miscarriage. A major question is how do we provide treatment? The trend in psychiatry over the past decade has been toward collaborative care, models that embed psychiatrists and other mental health clinicians in ob.gyn. practices to help guide the diagnosis and treatment of mental health problems. Some psychiatrists practice a co-located model in which they see patients alongside their ob.gyn. colleagues, whereas other psychiatrists treat a larger number of patients by using chart reviews for medication management while relying on behavioral health care managers for counseling and monitoring. Using this model of mental health care, more patients have access to services that are provided in a location familiar to them.

Another step in the right direction is the October 2019 launch of The National Curriculum in Reproductive Psychiatry (NCRP), which provides free educational material for psychiatry faculty and residents to enhance education on topics related to reproductive psychiatry, including miscarriage, loss, and development of trauma disorders. NCRP aspires to develop educational materials for ob.gyn. residents.

In the past we may have missed the mark in recognizing and treating the trauma that prenatal loss can cause, but we are trying to improve our approaches. More and more couples are sharing their experiences and advocating for themselves and others, often creating change in medical practice, and doctors are starting to listen. As any clinician knows, changes to standards of care can take several years to disseminate into general practice, but this gap between knowledge and treatment is now in the forefront of our minds. I am hopeful that we will continue to make advances and provide better care to our patients who have endured the loss of a pregnancy.
 

Dr. Latorre is an assistant professor in the department of psychiatry at the University of Maryland School of Medicine. She has reported no relevant financial disclosures. Email her at [email protected].

Numerous articles, books, and newspaper editorials have been written about the “crisis” in mental health care in our country from various perspectives, and the phrase is often used that the mental health system is “broken.” It seems that lately, this topic is often brought up after the most recent mass shooting.¹

Philip T. Yanos, PhD, correctly asked recently whether we should be talking about a “broken” system, because implicit in the phrase is the assumption that the mental health system was once “whole,” and he has pointed out² chronic deficiencies, such as the absence of affordable housing, and the availability of services to those with chronic mental illness.

In addition, many authors have asserted that, with deinstitutionalization – which occurred starting with the Community Mental Health Act of 1963 – homelessness also became a big problem for people in our prisons and jails, which became the default treatment providers for many of those with serious mental illness.Once authors make this point, they often offer up ways to start addressing various parts of the system, and it usually comes down to asking for more funding for more outpatient treatment and services as well as more inpatient beds. Some authors make the point³ that people with mental illness often lack insight into their illness and the need for treatment. Thus, we have the quandary of people with severe mental illness not believing that they need help, and thus not even trying to access services, which can lead to homelessness and jail time.

But what of those individuals with serious mental health problems who aren’t facing those obstacles and complications? What about individuals who aren’t facing homelessness, who haven’t gotten embroiled in the legal system, who do have insurance coverage, who live in areas with sufficient numbers of outpatient mental health centers to choose from, and who have no problems finding an inpatient bed when needed? Let’s suppose that we have an individual who does have insight into his mental illness and need for treatment, and is motivated to seek treatment. How responsive is the system to such individuals? That will be the focus on my article.

In a recent report,⁴ the author quotes American Psychiatric Association President Bruce J. Schwartz, MD, appealing to members of the U.S. Congress to step in. According to the author, Dr. Schwartz’s position is that the crisis in American mental health begins specifically with a drastic, and growing, shortage of psychiatric beds, especially in publicly funded state and county hospital beds. From there, the crisis spreads to the nation’s city streets, and its jails and prisons, where the largest number of people with serious mental illness now reside. He also talks about a shortage of psychiatrists and child psychiatrists, and says the shortage is likely to worsen. The proposed solution to this problem, of course, is more funding from Congress to open more psychiatric beds, as well as providing more funding for mental health in general and funding to residency programs to increase the numbers of psychiatrists.

I respect the opinions of Dr. Schwartz and that of the other authors who want to talk about lack of adequate beds, outpatient clinics and services, insufficient numbers of psychiatrists, and a lack of funding by Congress. However, I would like to provide further information, from a personal perspective, which causes me to believe that the problem is even more complex than that, and that the failures of the system are compounded by a dysfunctional culture within the ranks of professional caregivers. In other words, once the pieces are in place and assembled, the mental health system still seems to be “broken” but from within. I worry about apathy and an absence of motivation to provide good or even adequate services by the very people who are or should be aware of the problems and what it takes to help our vulnerable patients lead better lives.

I have practiced psychiatry for many years in various settings. I have spent many years working as an inpatient psychiatrist in a large state hospital. I have worked in community mental health outpatient settings. I have also worked in a private practice doing both inpatient and outpatient patient care as well as significant forensic work. At the hospitals, I have witnessed and prepared internal reports about patients who are “revolving doors.” Such patients often had more than 50 psychiatric hospitalizations and no apparent solution to keep them stable enough in the community.

But mental illness is not just a career for me. In addition to being psychiatrist, I am the father of a son with severe and persistent mental illness. I have watched him struggle to find stability. He, too, has been in and out of hospitals. My wife is also in the mental health field. She and I have endlessly tried to work with our son’s local community mental health center to provide them with feedback and to get them to respond to his needs – often with great frustration. It has been our impression that clinicians have difficulty listening to us and understanding the difficulties our son is having, from my son’s case manager to the treating psychiatrist, to the director of the agency. We have tried shifting him to other programs in a neighboring county, including one known to be a “model” program, but had the same issues.

Psychiatry is more of an art than science. Our other medical colleagues can try to resolve a clinical problem, no matter their rank, by ordering the right blood test or getting certain imaging. Psychiatry has no such biomarkers, or validated tests, to rely on to resolve disputes. We have only our training and experience and, unfortunately, our biases. If we don’t agree with a colleague, we often resort to rank and argument.

It is hard to hear, but psychiatrists sometimes resort to name-calling, often behind their colleagues’ backs, and to acting superior. There seems to be a certain attitude. Psychiatrists (just as can colleagues in other specialties) can be insufferably arrogant.

My personal experience has been that the hospital and the community often don’t communicate well. This seems to be a systems problem, as is the case for many complex unsolvable problems. I have been to discharge meetings involving hospital staff and the receiving community system. The attitude of the inpatient psychiatrist is often: “If you guys only did your job better, this patient wouldn’t keep having to be admitted. It’s your job to keep him out of the hospital.”

Alternatively, the community rejects this attitude and points to the absence of resources that prevents them from seeing patients in a timely manner and from adequately monitoring them. They say they are shackled by their resource constraints and that the endless admissions are inevitable. Further, the outpatient psychiatrists complain bitterly that all the inpatient doctors do is make a bunch of useless medication changes and then don’t keep patients in long enough to make sure the patient stays well. And on and on the arguments go with no resolution.

Sadly, and confirmed by my personal experience, when well-meaning and knowledgeable family members try to communicate with the community mental health system about their son’s mental disintegration, the community agency often doesn’t welcome the feedback. They resort to “confidentiality” concerns, often ill advised. Their opinion seems to be that the patient, (i.e. the patient who is falling apart and is becoming psychotic), should be the one calling the agency, waiting on hold forever, and not getting a call back. When my son has been in this situation, he has hung up his telephone out of frustration, then headed off to the emergency room, where he knew he would be seen.

The other area of frustration is that of the ideal of recovery. Mental health programs love to tout that their mission is “recovery,” and they list it as one of their primary areas of vision and goals. Yet, when we tried to communicate with community clinicians, they usually ignored our request to assist our son with supported employment and to help him achieve independence and a social life. When we tried to convey our recovery concerns to the psychiatrist, the usual response was also to ignore it and focus on “meds, meds, meds,” which most psychiatrists seem to view as their mission and area of expertise. Many psychiatrists have embraced the “bio-bio-bio” model of evaluation and treatment⁵ with only lip service paid to the “biopsychosocial” theory they like to say they advocate. When we reached out to our son’s psychiatrists and could get through, we found that they mostly failed to display much interest in paying attention to broader areas of functioning, instead focusing on symptoms, which they could observe in person.

So, I add to the chorus complaining that our mental health system is broken. Broken not only in terms of adequate funding, but also broken from within. It would require much wisdom and self-examination to even begin to address the problem. Without a better plan, throwing money at this broken system won’t improve the lives of our seriously ill and vulnerable psychiatric patients.
 

Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University in Cleveland as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.

References

1. Doroshow D. “We need to stop focusing on the mental health of mass shooters.” Washington Post. 2019 May 20.

2. Yanos P. “Is the mental health system ‘broken’?” Psychology Today. 2018 Oct 11.

3. Orenstein N. “How to fix a broken mental health system.” The Atlantic. 2016 Jun 8.

4. Moran M. APA rings alarm in nation’s capitol about crisis in mental health care. Psychiatr News. 2020 Jan 1.

5. Paris J. “Psychotherapy in an Age of Neuroscience.” New York: Oxford University Press, 2017.

Numerous articles, books, and newspaper editorials have been written about the “crisis” in mental health care in our country from various perspectives, and the phrase is often used that the mental health system is “broken.” It seems that lately, this topic is often brought up after the most recent mass shooting.¹

Philip T. Yanos, PhD, correctly asked recently whether we should be talking about a “broken” system, because implicit in the phrase is the assumption that the mental health system was once “whole,” and he has pointed out² chronic deficiencies, such as the absence of affordable housing, and the availability of services to those with chronic mental illness.

In addition, many authors have asserted that, with deinstitutionalization – which occurred starting with the Community Mental Health Act of 1963 – homelessness also became a big problem for people in our prisons and jails, which became the default treatment providers for many of those with serious mental illness.Once authors make this point, they often offer up ways to start addressing various parts of the system, and it usually comes down to asking for more funding for more outpatient treatment and services as well as more inpatient beds. Some authors make the point³ that people with mental illness often lack insight into their illness and the need for treatment. Thus, we have the quandary of people with severe mental illness not believing that they need help, and thus not even trying to access services, which can lead to homelessness and jail time.

But what of those individuals with serious mental health problems who aren’t facing those obstacles and complications? What about individuals who aren’t facing homelessness, who haven’t gotten embroiled in the legal system, who do have insurance coverage, who live in areas with sufficient numbers of outpatient mental health centers to choose from, and who have no problems finding an inpatient bed when needed? Let’s suppose that we have an individual who does have insight into his mental illness and need for treatment, and is motivated to seek treatment. How responsive is the system to such individuals? That will be the focus on my article.

In a recent report,⁴ the author quotes American Psychiatric Association President Bruce J. Schwartz, MD, appealing to members of the U.S. Congress to step in. According to the author, Dr. Schwartz’s position is that the crisis in American mental health begins specifically with a drastic, and growing, shortage of psychiatric beds, especially in publicly funded state and county hospital beds. From there, the crisis spreads to the nation’s city streets, and its jails and prisons, where the largest number of people with serious mental illness now reside. He also talks about a shortage of psychiatrists and child psychiatrists, and says the shortage is likely to worsen. The proposed solution to this problem, of course, is more funding from Congress to open more psychiatric beds, as well as providing more funding for mental health in general and funding to residency programs to increase the numbers of psychiatrists.

I respect the opinions of Dr. Schwartz and that of the other authors who want to talk about lack of adequate beds, outpatient clinics and services, insufficient numbers of psychiatrists, and a lack of funding by Congress. However, I would like to provide further information, from a personal perspective, which causes me to believe that the problem is even more complex than that, and that the failures of the system are compounded by a dysfunctional culture within the ranks of professional caregivers. In other words, once the pieces are in place and assembled, the mental health system still seems to be “broken” but from within. I worry about apathy and an absence of motivation to provide good or even adequate services by the very people who are or should be aware of the problems and what it takes to help our vulnerable patients lead better lives.

I have practiced psychiatry for many years in various settings. I have spent many years working as an inpatient psychiatrist in a large state hospital. I have worked in community mental health outpatient settings. I have also worked in a private practice doing both inpatient and outpatient patient care as well as significant forensic work. At the hospitals, I have witnessed and prepared internal reports about patients who are “revolving doors.” Such patients often had more than 50 psychiatric hospitalizations and no apparent solution to keep them stable enough in the community.

But mental illness is not just a career for me. In addition to being psychiatrist, I am the father of a son with severe and persistent mental illness. I have watched him struggle to find stability. He, too, has been in and out of hospitals. My wife is also in the mental health field. She and I have endlessly tried to work with our son’s local community mental health center to provide them with feedback and to get them to respond to his needs – often with great frustration. It has been our impression that clinicians have difficulty listening to us and understanding the difficulties our son is having, from my son’s case manager to the treating psychiatrist, to the director of the agency. We have tried shifting him to other programs in a neighboring county, including one known to be a “model” program, but had the same issues.

Psychiatry is more of an art than science. Our other medical colleagues can try to resolve a clinical problem, no matter their rank, by ordering the right blood test or getting certain imaging. Psychiatry has no such biomarkers, or validated tests, to rely on to resolve disputes. We have only our training and experience and, unfortunately, our biases. If we don’t agree with a colleague, we often resort to rank and argument.

It is hard to hear, but psychiatrists sometimes resort to name-calling, often behind their colleagues’ backs, and to acting superior. There seems to be a certain attitude. Psychiatrists (just as can colleagues in other specialties) can be insufferably arrogant.

My personal experience has been that the hospital and the community often don’t communicate well. This seems to be a systems problem, as is the case for many complex unsolvable problems. I have been to discharge meetings involving hospital staff and the receiving community system. The attitude of the inpatient psychiatrist is often: “If you guys only did your job better, this patient wouldn’t keep having to be admitted. It’s your job to keep him out of the hospital.”

Alternatively, the community rejects this attitude and points to the absence of resources that prevents them from seeing patients in a timely manner and from adequately monitoring them. They say they are shackled by their resource constraints and that the endless admissions are inevitable. Further, the outpatient psychiatrists complain bitterly that all the inpatient doctors do is make a bunch of useless medication changes and then don’t keep patients in long enough to make sure the patient stays well. And on and on the arguments go with no resolution.

Sadly, and confirmed by my personal experience, when well-meaning and knowledgeable family members try to communicate with the community mental health system about their son’s mental disintegration, the community agency often doesn’t welcome the feedback. They resort to “confidentiality” concerns, often ill advised. Their opinion seems to be that the patient, (i.e. the patient who is falling apart and is becoming psychotic), should be the one calling the agency, waiting on hold forever, and not getting a call back. When my son has been in this situation, he has hung up his telephone out of frustration, then headed off to the emergency room, where he knew he would be seen.

The other area of frustration is that of the ideal of recovery. Mental health programs love to tout that their mission is “recovery,” and they list it as one of their primary areas of vision and goals. Yet, when we tried to communicate with community clinicians, they usually ignored our request to assist our son with supported employment and to help him achieve independence and a social life. When we tried to convey our recovery concerns to the psychiatrist, the usual response was also to ignore it and focus on “meds, meds, meds,” which most psychiatrists seem to view as their mission and area of expertise. Many psychiatrists have embraced the “bio-bio-bio” model of evaluation and treatment⁵ with only lip service paid to the “biopsychosocial” theory they like to say they advocate. When we reached out to our son’s psychiatrists and could get through, we found that they mostly failed to display much interest in paying attention to broader areas of functioning, instead focusing on symptoms, which they could observe in person.

So, I add to the chorus complaining that our mental health system is broken. Broken not only in terms of adequate funding, but also broken from within. It would require much wisdom and self-examination to even begin to address the problem. Without a better plan, throwing money at this broken system won’t improve the lives of our seriously ill and vulnerable psychiatric patients.
 

Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University in Cleveland as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.

References

1. Doroshow D. “We need to stop focusing on the mental health of mass shooters.” Washington Post. 2019 May 20.

2. Yanos P. “Is the mental health system ‘broken’?” Psychology Today. 2018 Oct 11.

3. Orenstein N. “How to fix a broken mental health system.” The Atlantic. 2016 Jun 8.

4. Moran M. APA rings alarm in nation’s capitol about crisis in mental health care. Psychiatr News. 2020 Jan 1.

5. Paris J. “Psychotherapy in an Age of Neuroscience.” New York: Oxford University Press, 2017.

Numerous articles, books, and newspaper editorials have been written about the “crisis” in mental health care in our country from various perspectives, and the phrase is often used that the mental health system is “broken.” It seems that lately, this topic is often brought up after the most recent mass shooting.¹

Philip T. Yanos, PhD, correctly asked recently whether we should be talking about a “broken” system, because implicit in the phrase is the assumption that the mental health system was once “whole,” and he has pointed out² chronic deficiencies, such as the absence of affordable housing, and the availability of services to those with chronic mental illness.

In addition, many authors have asserted that, with deinstitutionalization – which occurred starting with the Community Mental Health Act of 1963 – homelessness also became a big problem for people in our prisons and jails, which became the default treatment providers for many of those with serious mental illness.Once authors make this point, they often offer up ways to start addressing various parts of the system, and it usually comes down to asking for more funding for more outpatient treatment and services as well as more inpatient beds. Some authors make the point³ that people with mental illness often lack insight into their illness and the need for treatment. Thus, we have the quandary of people with severe mental illness not believing that they need help, and thus not even trying to access services, which can lead to homelessness and jail time.

But what of those individuals with serious mental health problems who aren’t facing those obstacles and complications? What about individuals who aren’t facing homelessness, who haven’t gotten embroiled in the legal system, who do have insurance coverage, who live in areas with sufficient numbers of outpatient mental health centers to choose from, and who have no problems finding an inpatient bed when needed? Let’s suppose that we have an individual who does have insight into his mental illness and need for treatment, and is motivated to seek treatment. How responsive is the system to such individuals? That will be the focus on my article.

In a recent report,⁴ the author quotes American Psychiatric Association President Bruce J. Schwartz, MD, appealing to members of the U.S. Congress to step in. According to the author, Dr. Schwartz’s position is that the crisis in American mental health begins specifically with a drastic, and growing, shortage of psychiatric beds, especially in publicly funded state and county hospital beds. From there, the crisis spreads to the nation’s city streets, and its jails and prisons, where the largest number of people with serious mental illness now reside. He also talks about a shortage of psychiatrists and child psychiatrists, and says the shortage is likely to worsen. The proposed solution to this problem, of course, is more funding from Congress to open more psychiatric beds, as well as providing more funding for mental health in general and funding to residency programs to increase the numbers of psychiatrists.

I respect the opinions of Dr. Schwartz and that of the other authors who want to talk about lack of adequate beds, outpatient clinics and services, insufficient numbers of psychiatrists, and a lack of funding by Congress. However, I would like to provide further information, from a personal perspective, which causes me to believe that the problem is even more complex than that, and that the failures of the system are compounded by a dysfunctional culture within the ranks of professional caregivers. In other words, once the pieces are in place and assembled, the mental health system still seems to be “broken” but from within. I worry about apathy and an absence of motivation to provide good or even adequate services by the very people who are or should be aware of the problems and what it takes to help our vulnerable patients lead better lives.

I have practiced psychiatry for many years in various settings. I have spent many years working as an inpatient psychiatrist in a large state hospital. I have worked in community mental health outpatient settings. I have also worked in a private practice doing both inpatient and outpatient patient care as well as significant forensic work. At the hospitals, I have witnessed and prepared internal reports about patients who are “revolving doors.” Such patients often had more than 50 psychiatric hospitalizations and no apparent solution to keep them stable enough in the community.

But mental illness is not just a career for me. In addition to being psychiatrist, I am the father of a son with severe and persistent mental illness. I have watched him struggle to find stability. He, too, has been in and out of hospitals. My wife is also in the mental health field. She and I have endlessly tried to work with our son’s local community mental health center to provide them with feedback and to get them to respond to his needs – often with great frustration. It has been our impression that clinicians have difficulty listening to us and understanding the difficulties our son is having, from my son’s case manager to the treating psychiatrist, to the director of the agency. We have tried shifting him to other programs in a neighboring county, including one known to be a “model” program, but had the same issues.

Psychiatry is more of an art than science. Our other medical colleagues can try to resolve a clinical problem, no matter their rank, by ordering the right blood test or getting certain imaging. Psychiatry has no such biomarkers, or validated tests, to rely on to resolve disputes. We have only our training and experience and, unfortunately, our biases. If we don’t agree with a colleague, we often resort to rank and argument.

It is hard to hear, but psychiatrists sometimes resort to name-calling, often behind their colleagues’ backs, and to acting superior. There seems to be a certain attitude. Psychiatrists (just as can colleagues in other specialties) can be insufferably arrogant.

My personal experience has been that the hospital and the community often don’t communicate well. This seems to be a systems problem, as is the case for many complex unsolvable problems. I have been to discharge meetings involving hospital staff and the receiving community system. The attitude of the inpatient psychiatrist is often: “If you guys only did your job better, this patient wouldn’t keep having to be admitted. It’s your job to keep him out of the hospital.”

Alternatively, the community rejects this attitude and points to the absence of resources that prevents them from seeing patients in a timely manner and from adequately monitoring them. They say they are shackled by their resource constraints and that the endless admissions are inevitable. Further, the outpatient psychiatrists complain bitterly that all the inpatient doctors do is make a bunch of useless medication changes and then don’t keep patients in long enough to make sure the patient stays well. And on and on the arguments go with no resolution.

Sadly, and confirmed by my personal experience, when well-meaning and knowledgeable family members try to communicate with the community mental health system about their son’s mental disintegration, the community agency often doesn’t welcome the feedback. They resort to “confidentiality” concerns, often ill advised. Their opinion seems to be that the patient, (i.e. the patient who is falling apart and is becoming psychotic), should be the one calling the agency, waiting on hold forever, and not getting a call back. When my son has been in this situation, he has hung up his telephone out of frustration, then headed off to the emergency room, where he knew he would be seen.

The other area of frustration is that of the ideal of recovery. Mental health programs love to tout that their mission is “recovery,” and they list it as one of their primary areas of vision and goals. Yet, when we tried to communicate with community clinicians, they usually ignored our request to assist our son with supported employment and to help him achieve independence and a social life. When we tried to convey our recovery concerns to the psychiatrist, the usual response was also to ignore it and focus on “meds, meds, meds,” which most psychiatrists seem to view as their mission and area of expertise. Many psychiatrists have embraced the “bio-bio-bio” model of evaluation and treatment⁵ with only lip service paid to the “biopsychosocial” theory they like to say they advocate. When we reached out to our son’s psychiatrists and could get through, we found that they mostly failed to display much interest in paying attention to broader areas of functioning, instead focusing on symptoms, which they could observe in person.

So, I add to the chorus complaining that our mental health system is broken. Broken not only in terms of adequate funding, but also broken from within. It would require much wisdom and self-examination to even begin to address the problem. Without a better plan, throwing money at this broken system won’t improve the lives of our seriously ill and vulnerable psychiatric patients.
 

Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University in Cleveland as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.

References

1. Doroshow D. “We need to stop focusing on the mental health of mass shooters.” Washington Post. 2019 May 20.

2. Yanos P. “Is the mental health system ‘broken’?” Psychology Today. 2018 Oct 11.

3. Orenstein N. “How to fix a broken mental health system.” The Atlantic. 2016 Jun 8.

4. Moran M. APA rings alarm in nation’s capitol about crisis in mental health care. Psychiatr News. 2020 Jan 1.

5. Paris J. “Psychotherapy in an Age of Neuroscience.” New York: Oxford University Press, 2017.

Clinical Psychiatry News is pleased to welcome Alice W. Lee, MD, to its editorial advisory board.

Dr. Lee, who works with children, adolescents and adults, specializes in integrative and holistic psychiatry. In her private practice in Gaithersburg, Md., she integrates functional/orthomolecular medicine and mind–body/energy medicine in her work with patients.

She also writes and publishes weekly newsletters, and produces YouTube videos to an audience of more than 3,000 subscribers, followers, and website visitors per month. In addition, Dr. Lee is a Reiki master who integrates the biochemistry of chemistry with the quantum physics of healing. One of her specialties is helping patients withdraw from their psychiatric medications safely.

Dr. Lee is a member of the Academy of Integrative Health & Medicine, the Association for Comprehensive Energy Psychology, the Integrative Healthcare Symposium, and the Physicians Committee for Responsible Medicine.

Clinical Psychiatry News is pleased to welcome Alice W. Lee, MD, to its editorial advisory board.

Dr. Lee, who works with children, adolescents and adults, specializes in integrative and holistic psychiatry. In her private practice in Gaithersburg, Md., she integrates functional/orthomolecular medicine and mind–body/energy medicine in her work with patients.

She also writes and publishes weekly newsletters, and produces YouTube videos to an audience of more than 3,000 subscribers, followers, and website visitors per month. In addition, Dr. Lee is a Reiki master who integrates the biochemistry of chemistry with the quantum physics of healing. One of her specialties is helping patients withdraw from their psychiatric medications safely.

Dr. Lee is a member of the Academy of Integrative Health & Medicine, the Association for Comprehensive Energy Psychology, the Integrative Healthcare Symposium, and the Physicians Committee for Responsible Medicine.

Clinical Psychiatry News is pleased to welcome Alice W. Lee, MD, to its editorial advisory board.

Dr. Lee, who works with children, adolescents and adults, specializes in integrative and holistic psychiatry. In her private practice in Gaithersburg, Md., she integrates functional/orthomolecular medicine and mind–body/energy medicine in her work with patients.

She also writes and publishes weekly newsletters, and produces YouTube videos to an audience of more than 3,000 subscribers, followers, and website visitors per month. In addition, Dr. Lee is a Reiki master who integrates the biochemistry of chemistry with the quantum physics of healing. One of her specialties is helping patients withdraw from their psychiatric medications safely.

Dr. Lee is a member of the Academy of Integrative Health & Medicine, the Association for Comprehensive Energy Psychology, the Integrative Healthcare Symposium, and the Physicians Committee for Responsible Medicine.

Patients suffering from chronic pain who take medicinal cannabis to initiate and maintain sleep appear to experience short-term benefit, but long-term use may ultimately disrupt slumber, new research shows.

Investigators found whole-plant medical cannabis use was associated with fewer problems with respect to waking up at night, but they also found that frequent medical cannabis use was associated with more problems initiating and maintaining sleep.

LPETTET/Getty Images

A common problem

Estimates suggest chronic pain affects up to 37% of adults in the developed world. Individuals who suffer chronic pain often experience comorbid insomnia, which includes difficulty initiating sleep, sleep disruption, and early morning wakening.

For its part, medical cannabis to treat chronic pain symptoms and manage sleep problems has been widely reported as a prime motivation for medical cannabis use. Indeed, previous studies have concluded that the endocannabinoid system plays a role in sleep regulation, including sleep promotion and maintenance.

In recent years, investigators have reported the beneficial effects of medical cannabis for sleep. Nevertheless, some preclinical research has also concluded that chronic administration of tetrahydrocannabinol may result in tolerance to the sleep-enhancing effects of cannabis.

With that in mind, the researchers set out to examine the potential impact of whole-plant medicinal cannabis on sleep problems experienced by middle-aged patients suffering from chronic pain.

“People are self-reporting that they’re using cannabis for sleep and that it helps, but as we know, just because people are reporting that it works doesn’t mean that it will hold up in research,” Dr. Sznitman said.

The study included 128 individuals (mean age, 61±6 years; 51% females) with chronic neuropathic pain: 66 were medical cannabis users and 62 were not.

Three indicators of insomnia were measured using the 7-point Likert scale to assess issues with sleep initiation and maintenance.

In addition, investigators collected sociodemographic information, as well as data on daily consumption of tobacco, frequency of alcohol use, and pain severity. Finally, they collected patient data on the use of sleep-aid medications during the past month as well as tricyclic antidepressant use.
 

Frequent use, more sleep problems?

On average, medical cannabis users were 3 years younger than their nonusing counterparts (mean age, 60±6 vs. 63±6 years, respectively, P = .003) and more likely to be male (58% vs 40%, respectively, P = .038). Otherwise, the two groups were comparable.

Medical cannabis users reported taking the drug for an average of 4 years, at an average quantity of 31 g per month. The primary mode of administration was smoking (68.6%), followed by oil extracts (21.4%) and vaporization (20%).

Results showed that, of the total sample, 24.1% reported always waking up early and not falling back to sleep, 20.2% reported always having difficulty falling asleep, and 27.2% reported always waking up during the night.

After adjusting for patient age, sex, pain level, and use of sleep medications and antidepressants, medical cannabis use was associated with fewer problems with waking up at night, compared with nonmedical cannabis use. No differences were found between groups with respect to problems falling asleep or waking up early without being able to fall back to sleep, Dr. Sznitman and associates reported.

The final analysis of a subsample of patients that only included medical cannabis users showed frequency of medical cannabis use was associated with sleep problems, they said.

Specifically, more frequent cannabis use was associated with more problems related to waking up at night, as well as problems falling asleep.

Sleep problems associated with frequent medical cannabis use may signal the development of tolerance to the agent. However, frequent users of medical cannabis also maybsuffer pain or other comorbidities, which, in turn, may be linked to more sleep problems.

Either way, Dr. Sznitman said the study might open the door to another treatment option for patients suffering from chronic pain who struggle with sleep.

“If future research shows that the effect of medical cannabis on sleep is a consistent one, then we may be adding a new therapy for sleep problems, which are huge in society and especially in chronic pain patients,” she said.
 

Early days

Commenting on the findings in an interview, Ryan G. Vandrey, PhD, who was not involved in the study, said the findings are in line with previous research.

“I think the results make sense with respect to the data I’ve collected and from what I’ve seen,” said Dr. Vandrey, associate professor of psychiatry and behavioral sciences at Johns Hopkins Medicine in Baltimore.

“We typically only want to use sleep medications for short periods of time,” he continued. “When you think about recommended prescribing practices for any hypnotic medication, it’s usually short term, 2 weeks or less. Longer-term use often leads to tolerance, dependence, and withdrawal symptoms when the medication is stopped, which leads to an exacerbation of disordered sleep,” Dr. Vandrey said.

Nevertheless, he urged caution when interpreting the results.

“I think the study warrants caution about long-term daily use of cannabinoids with respect to sleep,” he said. “But we need more detailed evaluations, as the trial wasn’t testing a defined product, specific dose, or dose regimen.

“In addition, this was all done in the context of people with chronic pain and not treating disordered sleep or insomnia, but the study highlights the importance of recognizing that long-term chronic use of cannabis is not likely to fully resolve sleep problems.”

Dr. Sznitman agreed that the research is still in its very early stages.

“We’re still far from saying we have the evidence to support the use of medical cannabis for sleep,” she said. “For in the end it was just a cross-sectional, observational study, so we cannot say anything about cause and effect. But if these results pan out, they could be far-reaching and exciting.”

The study was funded by the University of Haifa and Rambam Hospital in Israel, and by the Evelyn Lipper Foundation. Dr. Sznitman and Dr. Vandrey have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.
 

Patients suffering from chronic pain who take medicinal cannabis to initiate and maintain sleep appear to experience short-term benefit, but long-term use may ultimately disrupt slumber, new research shows.

Investigators found whole-plant medical cannabis use was associated with fewer problems with respect to waking up at night, but they also found that frequent medical cannabis use was associated with more problems initiating and maintaining sleep.

LPETTET/Getty Images

A common problem

Estimates suggest chronic pain affects up to 37% of adults in the developed world. Individuals who suffer chronic pain often experience comorbid insomnia, which includes difficulty initiating sleep, sleep disruption, and early morning wakening.

For its part, medical cannabis to treat chronic pain symptoms and manage sleep problems has been widely reported as a prime motivation for medical cannabis use. Indeed, previous studies have concluded that the endocannabinoid system plays a role in sleep regulation, including sleep promotion and maintenance.

In recent years, investigators have reported the beneficial effects of medical cannabis for sleep. Nevertheless, some preclinical research has also concluded that chronic administration of tetrahydrocannabinol may result in tolerance to the sleep-enhancing effects of cannabis.

With that in mind, the researchers set out to examine the potential impact of whole-plant medicinal cannabis on sleep problems experienced by middle-aged patients suffering from chronic pain.

“People are self-reporting that they’re using cannabis for sleep and that it helps, but as we know, just because people are reporting that it works doesn’t mean that it will hold up in research,” Dr. Sznitman said.

The study included 128 individuals (mean age, 61±6 years; 51% females) with chronic neuropathic pain: 66 were medical cannabis users and 62 were not.

Three indicators of insomnia were measured using the 7-point Likert scale to assess issues with sleep initiation and maintenance.

In addition, investigators collected sociodemographic information, as well as data on daily consumption of tobacco, frequency of alcohol use, and pain severity. Finally, they collected patient data on the use of sleep-aid medications during the past month as well as tricyclic antidepressant use.
 

Frequent use, more sleep problems?

On average, medical cannabis users were 3 years younger than their nonusing counterparts (mean age, 60±6 vs. 63±6 years, respectively, P = .003) and more likely to be male (58% vs 40%, respectively, P = .038). Otherwise, the two groups were comparable.

Medical cannabis users reported taking the drug for an average of 4 years, at an average quantity of 31 g per month. The primary mode of administration was smoking (68.6%), followed by oil extracts (21.4%) and vaporization (20%).

Results showed that, of the total sample, 24.1% reported always waking up early and not falling back to sleep, 20.2% reported always having difficulty falling asleep, and 27.2% reported always waking up during the night.

After adjusting for patient age, sex, pain level, and use of sleep medications and antidepressants, medical cannabis use was associated with fewer problems with waking up at night, compared with nonmedical cannabis use. No differences were found between groups with respect to problems falling asleep or waking up early without being able to fall back to sleep, Dr. Sznitman and associates reported.

The final analysis of a subsample of patients that only included medical cannabis users showed frequency of medical cannabis use was associated with sleep problems, they said.

Specifically, more frequent cannabis use was associated with more problems related to waking up at night, as well as problems falling asleep.

Sleep problems associated with frequent medical cannabis use may signal the development of tolerance to the agent. However, frequent users of medical cannabis also maybsuffer pain or other comorbidities, which, in turn, may be linked to more sleep problems.

Either way, Dr. Sznitman said the study might open the door to another treatment option for patients suffering from chronic pain who struggle with sleep.

“If future research shows that the effect of medical cannabis on sleep is a consistent one, then we may be adding a new therapy for sleep problems, which are huge in society and especially in chronic pain patients,” she said.
 

Early days

Commenting on the findings in an interview, Ryan G. Vandrey, PhD, who was not involved in the study, said the findings are in line with previous research.

“I think the results make sense with respect to the data I’ve collected and from what I’ve seen,” said Dr. Vandrey, associate professor of psychiatry and behavioral sciences at Johns Hopkins Medicine in Baltimore.

“We typically only want to use sleep medications for short periods of time,” he continued. “When you think about recommended prescribing practices for any hypnotic medication, it’s usually short term, 2 weeks or less. Longer-term use often leads to tolerance, dependence, and withdrawal symptoms when the medication is stopped, which leads to an exacerbation of disordered sleep,” Dr. Vandrey said.

Nevertheless, he urged caution when interpreting the results.

“I think the study warrants caution about long-term daily use of cannabinoids with respect to sleep,” he said. “But we need more detailed evaluations, as the trial wasn’t testing a defined product, specific dose, or dose regimen.

“In addition, this was all done in the context of people with chronic pain and not treating disordered sleep or insomnia, but the study highlights the importance of recognizing that long-term chronic use of cannabis is not likely to fully resolve sleep problems.”

Dr. Sznitman agreed that the research is still in its very early stages.

“We’re still far from saying we have the evidence to support the use of medical cannabis for sleep,” she said. “For in the end it was just a cross-sectional, observational study, so we cannot say anything about cause and effect. But if these results pan out, they could be far-reaching and exciting.”

The study was funded by the University of Haifa and Rambam Hospital in Israel, and by the Evelyn Lipper Foundation. Dr. Sznitman and Dr. Vandrey have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.
 

Patients suffering from chronic pain who take medicinal cannabis to initiate and maintain sleep appear to experience short-term benefit, but long-term use may ultimately disrupt slumber, new research shows.

Investigators found whole-plant medical cannabis use was associated with fewer problems with respect to waking up at night, but they also found that frequent medical cannabis use was associated with more problems initiating and maintaining sleep.

LPETTET/Getty Images

A common problem

Estimates suggest chronic pain affects up to 37% of adults in the developed world. Individuals who suffer chronic pain often experience comorbid insomnia, which includes difficulty initiating sleep, sleep disruption, and early morning wakening.

For its part, medical cannabis to treat chronic pain symptoms and manage sleep problems has been widely reported as a prime motivation for medical cannabis use. Indeed, previous studies have concluded that the endocannabinoid system plays a role in sleep regulation, including sleep promotion and maintenance.

In recent years, investigators have reported the beneficial effects of medical cannabis for sleep. Nevertheless, some preclinical research has also concluded that chronic administration of tetrahydrocannabinol may result in tolerance to the sleep-enhancing effects of cannabis.

With that in mind, the researchers set out to examine the potential impact of whole-plant medicinal cannabis on sleep problems experienced by middle-aged patients suffering from chronic pain.

“People are self-reporting that they’re using cannabis for sleep and that it helps, but as we know, just because people are reporting that it works doesn’t mean that it will hold up in research,” Dr. Sznitman said.

The study included 128 individuals (mean age, 61±6 years; 51% females) with chronic neuropathic pain: 66 were medical cannabis users and 62 were not.

Three indicators of insomnia were measured using the 7-point Likert scale to assess issues with sleep initiation and maintenance.

In addition, investigators collected sociodemographic information, as well as data on daily consumption of tobacco, frequency of alcohol use, and pain severity. Finally, they collected patient data on the use of sleep-aid medications during the past month as well as tricyclic antidepressant use.
 

Frequent use, more sleep problems?

On average, medical cannabis users were 3 years younger than their nonusing counterparts (mean age, 60±6 vs. 63±6 years, respectively, P = .003) and more likely to be male (58% vs 40%, respectively, P = .038). Otherwise, the two groups were comparable.

Medical cannabis users reported taking the drug for an average of 4 years, at an average quantity of 31 g per month. The primary mode of administration was smoking (68.6%), followed by oil extracts (21.4%) and vaporization (20%).

Results showed that, of the total sample, 24.1% reported always waking up early and not falling back to sleep, 20.2% reported always having difficulty falling asleep, and 27.2% reported always waking up during the night.

After adjusting for patient age, sex, pain level, and use of sleep medications and antidepressants, medical cannabis use was associated with fewer problems with waking up at night, compared with nonmedical cannabis use. No differences were found between groups with respect to problems falling asleep or waking up early without being able to fall back to sleep, Dr. Sznitman and associates reported.

The final analysis of a subsample of patients that only included medical cannabis users showed frequency of medical cannabis use was associated with sleep problems, they said.

Specifically, more frequent cannabis use was associated with more problems related to waking up at night, as well as problems falling asleep.

Sleep problems associated with frequent medical cannabis use may signal the development of tolerance to the agent. However, frequent users of medical cannabis also maybsuffer pain or other comorbidities, which, in turn, may be linked to more sleep problems.

Either way, Dr. Sznitman said the study might open the door to another treatment option for patients suffering from chronic pain who struggle with sleep.

“If future research shows that the effect of medical cannabis on sleep is a consistent one, then we may be adding a new therapy for sleep problems, which are huge in society and especially in chronic pain patients,” she said.
 

Early days

Commenting on the findings in an interview, Ryan G. Vandrey, PhD, who was not involved in the study, said the findings are in line with previous research.

“I think the results make sense with respect to the data I’ve collected and from what I’ve seen,” said Dr. Vandrey, associate professor of psychiatry and behavioral sciences at Johns Hopkins Medicine in Baltimore.

“We typically only want to use sleep medications for short periods of time,” he continued. “When you think about recommended prescribing practices for any hypnotic medication, it’s usually short term, 2 weeks or less. Longer-term use often leads to tolerance, dependence, and withdrawal symptoms when the medication is stopped, which leads to an exacerbation of disordered sleep,” Dr. Vandrey said.

Nevertheless, he urged caution when interpreting the results.

“I think the study warrants caution about long-term daily use of cannabinoids with respect to sleep,” he said. “But we need more detailed evaluations, as the trial wasn’t testing a defined product, specific dose, or dose regimen.

“In addition, this was all done in the context of people with chronic pain and not treating disordered sleep or insomnia, but the study highlights the importance of recognizing that long-term chronic use of cannabis is not likely to fully resolve sleep problems.”

Dr. Sznitman agreed that the research is still in its very early stages.

“We’re still far from saying we have the evidence to support the use of medical cannabis for sleep,” she said. “For in the end it was just a cross-sectional, observational study, so we cannot say anything about cause and effect. But if these results pan out, they could be far-reaching and exciting.”

The study was funded by the University of Haifa and Rambam Hospital in Israel, and by the Evelyn Lipper Foundation. Dr. Sznitman and Dr. Vandrey have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.
 

Young people treated with bariatric surgery for severe obesity did not experience better mental health in the 5 years following their procedures, Swedish researchers said, and indeed fared worse than their nontreated peers on certain measures.

The results of this study do not necessarily argue “that metabolic and bariatric surgery during adolescence causes mental health problems,” the investigators wrote in the Lancet Child and Adolescent Health, but “it is reasonable to conclude that metabolic and bariatric surgery does not result in a substantial alleviation of mental health problems in adolescents with severe obesity,” and that “long-term mental health support should be required in programs providing adolescent metabolic and bariatric surgery.”

Kajsa Järvholm, PhD, of Skåne University Hospital, in Malmö, Sweden, and colleagues reported results from a prospective nonrandomized study that recruited 81 adolescents in Sweden aged 13-18 years (mean age, 16.5) who had a body mass index of 40 or higher, or BMI of 35 with obesity-related comorbidities and who underwent Roux-en-Y gastric bypass for weight loss. Subjects were matched by age, sex, and BMI to 80 controls (mean age, 15.8 years) who were assigned to conventional nonsurgical treatment. All patients were assessed at 1, 2, and 5 years.

Although mental health treatment, including use of psychiatric drugs, did not differ between the groups at baseline, during the follow-up period the subjects who underwent surgery saw 15% more impatient and outpatient mental health treatment, compared with controls, a significant difference. About a quarter of patients in the surgically treated group required specialized mental health treatment for the first time after their surgeries.

Though the surgical group lost much more weight – mean BMI was 32.3 at 5 years, compared with 41.7 for controls – none of the mental health changes from baseline were significantly associated with percentage change of BMI at 5 years.

The findings from the study are consistent with results from studies in adults in which bariatric surgery improves many health outcomes but does not alter the need for mental health treatment. Although 5 years is a longer follow-up than in previous studies in young patients – a key strength of the study – Dr. Järvholm and colleagues acknowledged some weaknesses, including a nonrandomized design, lack of a comparison group of nonobese youths for mental health measures, a small sample size, and a surgical procedure that is now out of favor in adolescents.

The study was funded by Swedish government and health foundations. Dr. Järvholm disclosed pharmaceutical industry funding not related to the study, and three coauthors also disclosed industry relationships.

SOURCE: Järvholm K et al. Lancet Child Adolesc Health. 2020. doi: 10.1016/s2352-4642(20)30024-9.

Young people treated with bariatric surgery for severe obesity did not experience better mental health in the 5 years following their procedures, Swedish researchers said, and indeed fared worse than their nontreated peers on certain measures.

The results of this study do not necessarily argue “that metabolic and bariatric surgery during adolescence causes mental health problems,” the investigators wrote in the Lancet Child and Adolescent Health, but “it is reasonable to conclude that metabolic and bariatric surgery does not result in a substantial alleviation of mental health problems in adolescents with severe obesity,” and that “long-term mental health support should be required in programs providing adolescent metabolic and bariatric surgery.”

Kajsa Järvholm, PhD, of Skåne University Hospital, in Malmö, Sweden, and colleagues reported results from a prospective nonrandomized study that recruited 81 adolescents in Sweden aged 13-18 years (mean age, 16.5) who had a body mass index of 40 or higher, or BMI of 35 with obesity-related comorbidities and who underwent Roux-en-Y gastric bypass for weight loss. Subjects were matched by age, sex, and BMI to 80 controls (mean age, 15.8 years) who were assigned to conventional nonsurgical treatment. All patients were assessed at 1, 2, and 5 years.

Although mental health treatment, including use of psychiatric drugs, did not differ between the groups at baseline, during the follow-up period the subjects who underwent surgery saw 15% more impatient and outpatient mental health treatment, compared with controls, a significant difference. About a quarter of patients in the surgically treated group required specialized mental health treatment for the first time after their surgeries.

Though the surgical group lost much more weight – mean BMI was 32.3 at 5 years, compared with 41.7 for controls – none of the mental health changes from baseline were significantly associated with percentage change of BMI at 5 years.

The findings from the study are consistent with results from studies in adults in which bariatric surgery improves many health outcomes but does not alter the need for mental health treatment. Although 5 years is a longer follow-up than in previous studies in young patients – a key strength of the study – Dr. Järvholm and colleagues acknowledged some weaknesses, including a nonrandomized design, lack of a comparison group of nonobese youths for mental health measures, a small sample size, and a surgical procedure that is now out of favor in adolescents.

The study was funded by Swedish government and health foundations. Dr. Järvholm disclosed pharmaceutical industry funding not related to the study, and three coauthors also disclosed industry relationships.

SOURCE: Järvholm K et al. Lancet Child Adolesc Health. 2020. doi: 10.1016/s2352-4642(20)30024-9.

Young people treated with bariatric surgery for severe obesity did not experience better mental health in the 5 years following their procedures, Swedish researchers said, and indeed fared worse than their nontreated peers on certain measures.

The results of this study do not necessarily argue “that metabolic and bariatric surgery during adolescence causes mental health problems,” the investigators wrote in the Lancet Child and Adolescent Health, but “it is reasonable to conclude that metabolic and bariatric surgery does not result in a substantial alleviation of mental health problems in adolescents with severe obesity,” and that “long-term mental health support should be required in programs providing adolescent metabolic and bariatric surgery.”

Kajsa Järvholm, PhD, of Skåne University Hospital, in Malmö, Sweden, and colleagues reported results from a prospective nonrandomized study that recruited 81 adolescents in Sweden aged 13-18 years (mean age, 16.5) who had a body mass index of 40 or higher, or BMI of 35 with obesity-related comorbidities and who underwent Roux-en-Y gastric bypass for weight loss. Subjects were matched by age, sex, and BMI to 80 controls (mean age, 15.8 years) who were assigned to conventional nonsurgical treatment. All patients were assessed at 1, 2, and 5 years.

Although mental health treatment, including use of psychiatric drugs, did not differ between the groups at baseline, during the follow-up period the subjects who underwent surgery saw 15% more impatient and outpatient mental health treatment, compared with controls, a significant difference. About a quarter of patients in the surgically treated group required specialized mental health treatment for the first time after their surgeries.

Though the surgical group lost much more weight – mean BMI was 32.3 at 5 years, compared with 41.7 for controls – none of the mental health changes from baseline were significantly associated with percentage change of BMI at 5 years.

The findings from the study are consistent with results from studies in adults in which bariatric surgery improves many health outcomes but does not alter the need for mental health treatment. Although 5 years is a longer follow-up than in previous studies in young patients – a key strength of the study – Dr. Järvholm and colleagues acknowledged some weaknesses, including a nonrandomized design, lack of a comparison group of nonobese youths for mental health measures, a small sample size, and a surgical procedure that is now out of favor in adolescents.

The study was funded by Swedish government and health foundations. Dr. Järvholm disclosed pharmaceutical industry funding not related to the study, and three coauthors also disclosed industry relationships.

SOURCE: Järvholm K et al. Lancet Child Adolesc Health. 2020. doi: 10.1016/s2352-4642(20)30024-9.

As the Wuhan coronavirus story unfolds, the most important thing for clinicians in the United States to do is ask patients who appear to have the flu if they, or someone they have been in contact with, recently returned from China, according to infectious disease experts.

China News Service/CC BY 3.0

“We are asking that of everyone with fever and respiratory symptoms who comes to our clinics, hospital, or emergency room. It’s a powerful screening tool,” said William Schaffner, MD, professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center, Nashville, Tenn.

In addition to fever, common signs of infection include cough, shortness of breath, and breathing difficulties. Some patients have had diarrhea, vomiting, and other gastrointestinal symptoms. In more severe cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure, and death. The incubation period appears to be up to 2 weeks, according to the World Health Organization (WHO).

If patients exhibit symptoms and either they or a close contact has returned from China recently, take standard airborne precautions and send specimens – a serum sample, oral and nasal pharyngeal swabs, and lower respiratory tract specimens if available – to the local health department, which will forward them to the Centers for Disease Control and Prevention (CDC) for testing. Turnaround time is 24-48 hours.

Plan and rehearse

The first step to prepare is to use the CDC’s Interim Guidance for Healthcare Professionals to make a written plan specific to your practice to respond to a potential case. The plan must include notifying the local health department, the CDC liaison for testing, and tracking down patient contacts.

“It’s not good enough to just download CDC’s guidance; use it to make your own local plan and know what to do 24/7,” said Daniel Lucey, MD, an infectious disease expert at Georgetown University Medical Center, Washington, D.C.

“Know who is on call at the health department on weekends and nights,” he said. Know where the patient is going to be isolated; figure out what to do if there’s more than one, and tests come back positive. Have masks on hand, and rehearse the response. “Make a coronavirus team, and absolutely have the nurses involved,” as well as other providers who may come into contact with a case, he added.

Fatality rates

The focus right now is China. The outbreak has spread beyond Wuhan to other parts of the country, and there’s evidence of fourth-generation spread.

SARS: Lessons learned

In general, the world is much better equipped for coronavirus outbreaks than when SARS, in particular, emerged in 2003.

[email protected]

This article was updated with new case numbers on 1/26/20.

As the Wuhan coronavirus story unfolds, the most important thing for clinicians in the United States to do is ask patients who appear to have the flu if they, or someone they have been in contact with, recently returned from China, according to infectious disease experts.

China News Service/CC BY 3.0

“We are asking that of everyone with fever and respiratory symptoms who comes to our clinics, hospital, or emergency room. It’s a powerful screening tool,” said William Schaffner, MD, professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center, Nashville, Tenn.

In addition to fever, common signs of infection include cough, shortness of breath, and breathing difficulties. Some patients have had diarrhea, vomiting, and other gastrointestinal symptoms. In more severe cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure, and death. The incubation period appears to be up to 2 weeks, according to the World Health Organization (WHO).

If patients exhibit symptoms and either they or a close contact has returned from China recently, take standard airborne precautions and send specimens – a serum sample, oral and nasal pharyngeal swabs, and lower respiratory tract specimens if available – to the local health department, which will forward them to the Centers for Disease Control and Prevention (CDC) for testing. Turnaround time is 24-48 hours.

Plan and rehearse

The first step to prepare is to use the CDC’s Interim Guidance for Healthcare Professionals to make a written plan specific to your practice to respond to a potential case. The plan must include notifying the local health department, the CDC liaison for testing, and tracking down patient contacts.

“It’s not good enough to just download CDC’s guidance; use it to make your own local plan and know what to do 24/7,” said Daniel Lucey, MD, an infectious disease expert at Georgetown University Medical Center, Washington, D.C.

“Know who is on call at the health department on weekends and nights,” he said. Know where the patient is going to be isolated; figure out what to do if there’s more than one, and tests come back positive. Have masks on hand, and rehearse the response. “Make a coronavirus team, and absolutely have the nurses involved,” as well as other providers who may come into contact with a case, he added.

Fatality rates

The focus right now is China. The outbreak has spread beyond Wuhan to other parts of the country, and there’s evidence of fourth-generation spread.

SARS: Lessons learned

In general, the world is much better equipped for coronavirus outbreaks than when SARS, in particular, emerged in 2003.

[email protected]

This article was updated with new case numbers on 1/26/20.

As the Wuhan coronavirus story unfolds, the most important thing for clinicians in the United States to do is ask patients who appear to have the flu if they, or someone they have been in contact with, recently returned from China, according to infectious disease experts.

China News Service/CC BY 3.0

“We are asking that of everyone with fever and respiratory symptoms who comes to our clinics, hospital, or emergency room. It’s a powerful screening tool,” said William Schaffner, MD, professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center, Nashville, Tenn.

In addition to fever, common signs of infection include cough, shortness of breath, and breathing difficulties. Some patients have had diarrhea, vomiting, and other gastrointestinal symptoms. In more severe cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure, and death. The incubation period appears to be up to 2 weeks, according to the World Health Organization (WHO).

If patients exhibit symptoms and either they or a close contact has returned from China recently, take standard airborne precautions and send specimens – a serum sample, oral and nasal pharyngeal swabs, and lower respiratory tract specimens if available – to the local health department, which will forward them to the Centers for Disease Control and Prevention (CDC) for testing. Turnaround time is 24-48 hours.

Plan and rehearse

The first step to prepare is to use the CDC’s Interim Guidance for Healthcare Professionals to make a written plan specific to your practice to respond to a potential case. The plan must include notifying the local health department, the CDC liaison for testing, and tracking down patient contacts.

“It’s not good enough to just download CDC’s guidance; use it to make your own local plan and know what to do 24/7,” said Daniel Lucey, MD, an infectious disease expert at Georgetown University Medical Center, Washington, D.C.

“Know who is on call at the health department on weekends and nights,” he said. Know where the patient is going to be isolated; figure out what to do if there’s more than one, and tests come back positive. Have masks on hand, and rehearse the response. “Make a coronavirus team, and absolutely have the nurses involved,” as well as other providers who may come into contact with a case, he added.

Fatality rates

The focus right now is China. The outbreak has spread beyond Wuhan to other parts of the country, and there’s evidence of fourth-generation spread.

SARS: Lessons learned

In general, the world is much better equipped for coronavirus outbreaks than when SARS, in particular, emerged in 2003.

[email protected]

This article was updated with new case numbers on 1/26/20.

The U.S. Surgeon General is calling on all physicians to help patients stop smoking, noting that two-thirds of adult smokers say they want to quit, but only 40% report that their doctor has advised them to stop.

“I’ve got to own this as the nation’s doctor, and our health providers in this room and in this country need to own this stat,” said Surgeon General Jerome Adams, MD, at a press briefing releasing a new report on smoking cessation.

“Smoking is the No. 1 preventable cause of death, disease, and disability in the United States,” he said. “So why are 40% of our health providers out there not advising smokers to quit when they come in?”

In the first U.S. Surgeon General report on smoking cessation in 30 years, the 700-page report suggests smoking cessation-related quality measures that include physician reimbursement would increase treatment.

The evidence also suggests that using electronic health records to prompt clinicians to inquire about smoking would increase cessation treatment.

EHRs could be used to “empower and enable” physicians to advise people to quit, said Dr. Adams. Physicians also need “the education and the confidence to be able to have that conversation, because too many of them look at someone and say: ‘Nope, too hard, too much effort, no, that’s not what they’re here for today,’ ” he said.

However, “simply asking, advising, and referring can be enough to get someone on the pathway to quitting,” Dr. Adams said.
 

34 million still smoke

The new report is the first on the topic released since 1990, and the 34th on tobacco control since the first one was issued in 1964, said Dr. Adams. Since that first report, adult smoking has declined 70%, but some 34 million Americans (14%) still smoke, he said.

In addition, Dr. Adams said that many subpopulations have been left behind, noting: “Cigarette smoking remains highest among LGBTQ adults, people with disabilities or limitations, American Indians and Alaska Natives, and people with mental health conditions or substance use disorders.”

He also noted that 40% of cigarettes are consumed by those with a mental illness or a substance use disorder.

Quitting is beneficial at any age and can add as much as a decade to life expectancy, the report notes. Quitting also reduces the risk of 12 cancers, cuts the risk of chronic obstructive pulmonary disease, and reduces cardiovascular and stroke morbidity and mortality.

Pregnant women who quit also reduce their own morbidity and mortality risk and that of unborn children and infants, the report says.

“We know more about the science of quitting than ever before. We can, and must, do more to ensure that evidence-based cessation treatments are reaching the people that need them,” said Dr. Adams.

Less than one-third of those who have quit have used Food and Drug Administration–approved cessation medications or behavioral counseling, Dr. Adams said.
 

Barriers to care

Despite the existence of five nicotine replacement therapies and two nonnicotine oral medications, and more widespread availability of proven counseling methods – including web- or text-based programs – barriers to access remain.

These include a lack of insurance coverage for comprehensive, evidence-based smoking cessation treatment, which, when offered, increases availability and use.

“These are cost-effective interventions,” said Dr. Adams. “It’s penny wise and pound foolish to not give someone access to what we know works,” he said.

Because of the diversity of e-cigarette products and the variety of ways they are used, coupled with little research, it’s not currently possible to determine whether they are, or are not, useful smoking cessation tools, the report notes.

However, experts who compiled the report found some evidence to suggest that e-cigarettes containing nicotine may be “associated with increased smoking cessation compared with the use of e-cigarettes not containing nicotine.”

Asked whether the report’s conclusions might be interpreted as supportive of e-cigarettes, Dr. Adams said the report focused on smoking cessation, not initiation.

“I’m terribly concerned about the clear data that shows youth are initiating tobacco product use with e-cigarettes,” he said.

The Trump administration’s current proposal to partially restrict sales of some flavored e-cigarettes “reflects the science,” and “a balance between a desire to really make sure that people aren’t initiating with these products, but also a desire to again try to maintain a pathway for adults who want to use these products to quit to use them,” Dr. Adams said.

The focus, said Dr. Adams, should not be on e-cigarettes and whether they do, or do not, work.

“People want to quit,” he said. “We know what works. Not enough of them are getting it, and there are terrible disparities in who is and who is not getting access to effective and evidence-based treatment – that’s the story here.”

This article first appeared on Medscape.com.

The U.S. Surgeon General is calling on all physicians to help patients stop smoking, noting that two-thirds of adult smokers say they want to quit, but only 40% report that their doctor has advised them to stop.

“I’ve got to own this as the nation’s doctor, and our health providers in this room and in this country need to own this stat,” said Surgeon General Jerome Adams, MD, at a press briefing releasing a new report on smoking cessation.

“Smoking is the No. 1 preventable cause of death, disease, and disability in the United States,” he said. “So why are 40% of our health providers out there not advising smokers to quit when they come in?”

In the first U.S. Surgeon General report on smoking cessation in 30 years, the 700-page report suggests smoking cessation-related quality measures that include physician reimbursement would increase treatment.

The evidence also suggests that using electronic health records to prompt clinicians to inquire about smoking would increase cessation treatment.

EHRs could be used to “empower and enable” physicians to advise people to quit, said Dr. Adams. Physicians also need “the education and the confidence to be able to have that conversation, because too many of them look at someone and say: ‘Nope, too hard, too much effort, no, that’s not what they’re here for today,’ ” he said.

However, “simply asking, advising, and referring can be enough to get someone on the pathway to quitting,” Dr. Adams said.
 

34 million still smoke

The new report is the first on the topic released since 1990, and the 34th on tobacco control since the first one was issued in 1964, said Dr. Adams. Since that first report, adult smoking has declined 70%, but some 34 million Americans (14%) still smoke, he said.

In addition, Dr. Adams said that many subpopulations have been left behind, noting: “Cigarette smoking remains highest among LGBTQ adults, people with disabilities or limitations, American Indians and Alaska Natives, and people with mental health conditions or substance use disorders.”

He also noted that 40% of cigarettes are consumed by those with a mental illness or a substance use disorder.

Quitting is beneficial at any age and can add as much as a decade to life expectancy, the report notes. Quitting also reduces the risk of 12 cancers, cuts the risk of chronic obstructive pulmonary disease, and reduces cardiovascular and stroke morbidity and mortality.

Pregnant women who quit also reduce their own morbidity and mortality risk and that of unborn children and infants, the report says.

“We know more about the science of quitting than ever before. We can, and must, do more to ensure that evidence-based cessation treatments are reaching the people that need them,” said Dr. Adams.

Less than one-third of those who have quit have used Food and Drug Administration–approved cessation medications or behavioral counseling, Dr. Adams said.
 

Barriers to care

Despite the existence of five nicotine replacement therapies and two nonnicotine oral medications, and more widespread availability of proven counseling methods – including web- or text-based programs – barriers to access remain.

These include a lack of insurance coverage for comprehensive, evidence-based smoking cessation treatment, which, when offered, increases availability and use.

“These are cost-effective interventions,” said Dr. Adams. “It’s penny wise and pound foolish to not give someone access to what we know works,” he said.

Because of the diversity of e-cigarette products and the variety of ways they are used, coupled with little research, it’s not currently possible to determine whether they are, or are not, useful smoking cessation tools, the report notes.

However, experts who compiled the report found some evidence to suggest that e-cigarettes containing nicotine may be “associated with increased smoking cessation compared with the use of e-cigarettes not containing nicotine.”

Asked whether the report’s conclusions might be interpreted as supportive of e-cigarettes, Dr. Adams said the report focused on smoking cessation, not initiation.

“I’m terribly concerned about the clear data that shows youth are initiating tobacco product use with e-cigarettes,” he said.

The Trump administration’s current proposal to partially restrict sales of some flavored e-cigarettes “reflects the science,” and “a balance between a desire to really make sure that people aren’t initiating with these products, but also a desire to again try to maintain a pathway for adults who want to use these products to quit to use them,” Dr. Adams said.

The focus, said Dr. Adams, should not be on e-cigarettes and whether they do, or do not, work.

“People want to quit,” he said. “We know what works. Not enough of them are getting it, and there are terrible disparities in who is and who is not getting access to effective and evidence-based treatment – that’s the story here.”

This article first appeared on Medscape.com.

The U.S. Surgeon General is calling on all physicians to help patients stop smoking, noting that two-thirds of adult smokers say they want to quit, but only 40% report that their doctor has advised them to stop.

“I’ve got to own this as the nation’s doctor, and our health providers in this room and in this country need to own this stat,” said Surgeon General Jerome Adams, MD, at a press briefing releasing a new report on smoking cessation.

“Smoking is the No. 1 preventable cause of death, disease, and disability in the United States,” he said. “So why are 40% of our health providers out there not advising smokers to quit when they come in?”

In the first U.S. Surgeon General report on smoking cessation in 30 years, the 700-page report suggests smoking cessation-related quality measures that include physician reimbursement would increase treatment.

The evidence also suggests that using electronic health records to prompt clinicians to inquire about smoking would increase cessation treatment.

EHRs could be used to “empower and enable” physicians to advise people to quit, said Dr. Adams. Physicians also need “the education and the confidence to be able to have that conversation, because too many of them look at someone and say: ‘Nope, too hard, too much effort, no, that’s not what they’re here for today,’ ” he said.

However, “simply asking, advising, and referring can be enough to get someone on the pathway to quitting,” Dr. Adams said.
 

34 million still smoke

The new report is the first on the topic released since 1990, and the 34th on tobacco control since the first one was issued in 1964, said Dr. Adams. Since that first report, adult smoking has declined 70%, but some 34 million Americans (14%) still smoke, he said.

In addition, Dr. Adams said that many subpopulations have been left behind, noting: “Cigarette smoking remains highest among LGBTQ adults, people with disabilities or limitations, American Indians and Alaska Natives, and people with mental health conditions or substance use disorders.”

He also noted that 40% of cigarettes are consumed by those with a mental illness or a substance use disorder.

Quitting is beneficial at any age and can add as much as a decade to life expectancy, the report notes. Quitting also reduces the risk of 12 cancers, cuts the risk of chronic obstructive pulmonary disease, and reduces cardiovascular and stroke morbidity and mortality.

Pregnant women who quit also reduce their own morbidity and mortality risk and that of unborn children and infants, the report says.

“We know more about the science of quitting than ever before. We can, and must, do more to ensure that evidence-based cessation treatments are reaching the people that need them,” said Dr. Adams.

Less than one-third of those who have quit have used Food and Drug Administration–approved cessation medications or behavioral counseling, Dr. Adams said.
 

Barriers to care

Despite the existence of five nicotine replacement therapies and two nonnicotine oral medications, and more widespread availability of proven counseling methods – including web- or text-based programs – barriers to access remain.

These include a lack of insurance coverage for comprehensive, evidence-based smoking cessation treatment, which, when offered, increases availability and use.

“These are cost-effective interventions,” said Dr. Adams. “It’s penny wise and pound foolish to not give someone access to what we know works,” he said.

Because of the diversity of e-cigarette products and the variety of ways they are used, coupled with little research, it’s not currently possible to determine whether they are, or are not, useful smoking cessation tools, the report notes.

However, experts who compiled the report found some evidence to suggest that e-cigarettes containing nicotine may be “associated with increased smoking cessation compared with the use of e-cigarettes not containing nicotine.”

Asked whether the report’s conclusions might be interpreted as supportive of e-cigarettes, Dr. Adams said the report focused on smoking cessation, not initiation.

“I’m terribly concerned about the clear data that shows youth are initiating tobacco product use with e-cigarettes,” he said.

The Trump administration’s current proposal to partially restrict sales of some flavored e-cigarettes “reflects the science,” and “a balance between a desire to really make sure that people aren’t initiating with these products, but also a desire to again try to maintain a pathway for adults who want to use these products to quit to use them,” Dr. Adams said.

The focus, said Dr. Adams, should not be on e-cigarettes and whether they do, or do not, work.

“People want to quit,” he said. “We know what works. Not enough of them are getting it, and there are terrible disparities in who is and who is not getting access to effective and evidence-based treatment – that’s the story here.”

This article first appeared on Medscape.com.